This form must be completed prior to your first appointment. For your convenience, you may complete the form below and submit it online directly to our office. If you prefer you may print the forms and bring* them with you to your appointment, however, this WILL increase your wait time. *If you bring registration forms with you, please plan to arrive 20 minutes before your appointment time.
  • Patient Information

  • If referred by a Physician please give full name and phone number.
  • Insurance Information

  • Medicare Insurance Information

  • Do not use dashes
  • Secondary Insurance Information (for Medicare patients only)

  • Self Pay

  • Patient Medical History

  • "NOT MEDICALLY NECESSARY" OR "COSMETIC PROCEDURES"

  • With the changes evident in the health care industry, more and more insurance companies are instituting restrictions on covered procedures. Our office is aware of many procedures that are considered "not medically necessary" or "cosmetic" and will make an attempt to alert you of these procedures. If you and your physician decide to continue with a procedure that falls into this category, we require payment in full at the time of service. There is no reduction in fee for HMO, PPO, or Medicare patients for these procedures. If you have any questions or concerns about what is considered "not medically necessary" or "cosmetic", please do not hesitate to discuss the above with your physician or with any member of our staff. We will be happy to assist you with any of your questions or concerns. CANCELLATIONS AND MISSED APPOINTMENTS We ask that you please make every effort to keep your appointment. If you must cancel or reschedule, we require at least 24 hours notice so that proper scheduling can be maintained. As of January 1, 2008, there will be a fee of $25.00 for all appointments that are missed or cancelled without 24 Hour notice. RETURNED CHECKS Our office will turn over returned checks to the District Attorney's office for collection. We charge a $25.00 service charge on all returned checks. COLLECTION EFFORTS We require payment in full at the time services are rendered. Should your account show a balance for any reason, we will make every effort to work with you to make payment arrangements. If all of these efforts do not bring about resolution of the account, the account will be turned over to a collection agency. Any fees assessed to our office by the collection agency will be passed on to your account. I HAVE READ AND UNDERSTAND THE ABOVE AND AGREE TO COMPLY WITH THE FINANCIAL POLICIES OF KINGWOOD DERMATOLOGY.
  • By providing my consent to West Houston Dermatology Laser and Skin Care Center I acknowledge that I am the Patient (or Parent if patient is a minor) and that all the information provided is accurate. By clicking the "I Agree" button at the bottom of this box, you will be able to submit this form to Kingwood Dermatology. If you do NOT agree or not able to provide your consent to electronically sign this online form you must contact us in writing at info@kingwoodderm.com or by phone at (281) 359-6000 and click "I don't Agree". Your form will not be completed and your request will not be sent to Kingwood Dermatology.