Damascus Dermatology Appointment Request Form

This is a secure form. Upon processing this form you will receive a call from the office to arrange an appointment date and time. Please note that online registration forms submitted after 4 p.m. will be processed the next business day. Any forms submitted over the weekend, or holidays will be processed the next business day.

Have you been seen as a patient at Damascus Dermatology within the past 3 years?*

Yes No I Don't Know

Damascus Dermatology Now Offers TeleDermatology Visits

AVAILABLE FOR CURRENT AND EXISTING PATIENTS WITH SPECIFIC CONDITIONS

Our staff will contact you shortly to schedule the visit you requested. I would like to request the following type of visit:

Virtual Visit Using TeleDermatology Traditional In-Office Visit

By selecting a virtual visit using TeleDermatology, you are consenting to voluntarily be evaluated and managed in a video-conference with a physician or nurse practitioner and a medical assistant.

Full Patient Name:*

Prefix (optional)

First Name

Initial (optional)

Last Name

Has your address changed since your last visit?*

Yes No

Home Address:*

Address Line 1

Address Line 2

City

State

ZIP Code

Country

Primary Contact Phone Number:*

Email

Confirm Email *

Date of Birth:*

Has your insurance changed since your last visit?*

Yes No

Type of Insurance:*

Please bring your current insurance information / card to your visit.

Primary Chief Complaint

Please explain your chief complaint, the body location of the problem, any associated symptoms, and the duration and trend of the condition. You can also specify full skin check if applicable.*

How long have you had the symptoms?

Do you have a SECOND chief complaint?

Yes No

How long have you had the symptoms?

Are you taking medications:*

I am not taking medications I am taking medications No change since last visit

List all medications that you are currently taking.

Drug Allergies*

No known drug allergies I have drug allergies No change since last visit

List any drug allergies and associated reactions.

Assignment of Insurance Benefits*

I have read and agree to the Assignment of Insurance Benefits

By checking the box above, I assign all medical benefits to which I am entitled to DAL Dermatology, Inc. This assignment shall remain in effect until revoked by me in writing. I understand that I am responsible for all charges not paid by insurance. I hereby authorize DAL Dermatology, Inc. to release all necessary information to insurance companies and billing agencies.

Laboratory and Pathology Billing*

I have read and agree to the Laboratory and Pathology Billing

By checking the box above, I understand that my insurance may or may not cover my laboratory and pathology billing in full and that I am responsible for all laboratory and pathology charges not paid by my insurance. I also acknowledge that my biopsy or surgery specimen(s) will be sent to an appropriate in-network laboratory (Annapath Inc., LabCorp, or Mid-Atlantic Pathology Services) for processing into glass slides. These slides will then be read by Dr. Ilene Bayer-Garner, MD, for diagnosis. In extremely rare instances, I understand that Dr. Bayer-Garner may enlist an additional specialist for a second opinion if a complex diagnosis is being entertained and additional charges may occur.

Acknowledgement of Office Policies and Privacy Practices*

I have read and agree to the Office Policies and Notice of Privacy Practices

By checking the box above, I acknowledge that I have read and understood the Damascus Dermatology & Skin Surgery Center Office Policies (click here) and Notice of Privacy Practices (click here). These documents are also posted on our website (www.damascusderm.com) and are always made available at the reception desk.

This is a secure form. Upon processing this form you will receive a call from the office to arrange an appointment date and time. Please note that online registration forms submitted after 4 p.m. will be processed the next business day. Any forms submitted over the weekend, or holidays will be processed the next business day.