North Metro Dermatology

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Patient Registration

If you are a human and are seeing this field, please leave it blank.

Fields marked with an * are required

Last Name *

First Name *

Date of Birth *

Home Address *

City *

State *

Zip Code *

Work Phone

Home Phone *

Cell Phone

Preferred Method of Contact *

Home
Work
Cell

Sex *

Marital Status *

Email *

We send out just 1 email each month and do not sell or loan personal information regarding our customers to third parties. Would you like to receive our monthly newsletter? *

Yes
No

Race / Ethnicity (select all that apply) *

American Indian
Alaskan Native
Native Hawaiian or Pacific Islander
White, not of Hispanic Origin
Hispanic or Latino
Asian
Black, or African American, not of Hispanic Origin
Other

Preferred Language *

Preferred Pharmacy / Location / Phone *

If does not apply, please type "N/A"

Referring Doctor *

If does not apply, please type "N/A"

Primary MD *

If does not apply, please type "N/A"

Emergency Contact Name *

If does not apply, please type "N/A"

Emergency Contact Relationship *

If does not apply, please type "N/A"

Emergency Contact Phone *

If does not apply, please type "N/A"

How did you hear about our practice? *

Insurance Plan
Advertisement
Family
Friend
Internet
LA / Planet Fitness
Magazine
Provider
Other

RESPONSIBLE PARTY INFORMATION (if patient under 18):

Last Name

First Name

Relationship to Patient

Date of Birth

Home Phone

Cell Phone

Work Phone

Address

City

State

Zip Code

INSURANCE INFORMATION

Primary Insurance Plan *

Member ID # *

Group # *

Policy Holder *

Date of Birth *

Relationship to Patient *

Policy Holder Address (if different than patient) *

Secondary Insurance Plan

Member ID #

Group #

Policy Holder

Date of Birth

Relationship to Patient

Address (if different than patient)

By typing my full name below, I acknowledge that I have been provided or will be provided with a copy of Privacy Practices from North Metro Dermatology. *

CONTACT INFORMATION

North Metro Dermatology
400 Village Center Drive, Suite 200
North Oaks MN 55127
(651) 789-9800
reception@northmetroderm.com

Forms
Insurance
Policies
Assignment of Benefits
Authorization for Release of Medical Record Information

GENERAL HOURS

Monday – Friday
8 AM – 5 PM
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