PATIENT FORMS

For any questions on our company or our services call or stop in at one of our two locations; Riverview, MI at 734-282-7266 or Lake Orion, MI at 248-690-7243.

New Patients

On the day of your appointment, please bring the following with you

  • Completed paperwork
  • Insurance cards and photo ID
  • A list of any medications and products that you are currently using

Do not use moisturizer, sunscreen or aftershave on the day of your appointment
If you wear makeup, you may wish to bring it with you to refresh prior to continuing your day
If your appointment is for a mole check/body exam, loose fitting clothing should be worn

Patient Information Form

Notice of Privacy Practices

Insurance Verification Form

Patient History Form

CDV Acknowledgment Policy Form

CDV Financial Policy Form

 

Existing Medical Patients

Medical history needs to be updated every 11 months. In order to ensure that we have your most up to date history, please inform us of any changes in your history

Bring an updated medication/product list for your record
Please have insurance cards and photo ID with you as we may require an updated copy
Do not use moisturizer, sunscreen or aftershave on the day of your appointment
Wear loose fitting clothing if your appointment is for a mole check/body exam

 

New Vein Patients

To optimize our exam, when you arrive for your appointment, please remain standing in the lobby and exam room.

Wearing/bringing a pair of shorts is preferable

If you have not been seen for this condition prior to today, you will require evaluation prior to any treatment being performed

Please inquire with your insurance company regarding your benefits and coverage for treatment. Keep in mind that although your insurance may state that the procedure is a covered benefit, your condition may or may not meet the criteria necessary for coverage.

Patient Information Form

Notice of Privacy Practices

Insurance Verification Form

CDV Acknowledgment Policy Form

CDV Financial Policy Form

Vein Patient History

 

Existing Vein Patients

Vein Patient History needs to be updated every 11 months

Wearing/bringing a pair of shorts is preferable

If you have not been seen for this condition for greater than 1 year, you may require re-evaluation prior to treatment.

To optimize our exam, when you arrive for your appointment, please remain standing in the lobby and exam room.

Vein Patient History

 

New Cosmetic Patients

If you wear makeup, you may wish to bring it with you to refresh prior to continuing your day

Patient Information Form

 

Blue Care Network (BCN) insurance requires a referral from your primary care physician (PCP). Please make sure to contact your PCP at least one week prior to your appointment to obtain your referral. We will make every attempt to keep your PCP informed of your coordination of care and any future appointments but ultimately it is your responsibility to ensure that you have an active referral for your appointment. If you do not have an active referral on the date of your appointment, we will have to reschedule your appointment for another day.

Health Alliance Plan (HAP) insurance requires that you be referred by your primary care physician (PCP). You do not need a traditional referral but rather a prescription from the PCP stating that you need to be seen by a dermatologist.

For any procedure – please contact your insurance company prior to the date of procedure to determine coverage in order to avoid disappointment.