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Get In Touch with Aylesworth Dermatology

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Aylesworth Dermatology SC
550 E Timber Dr Ste 1
Rhinelander, WI 54501
Located in the Northwoods of Wisconsin

Fax: 949-862-7646

Please use the form to contact Aylesworth Dermatology. We will respond as soon as possible.

Name

Email

Phone

Message

Patient Forms

Welcome to Dr. Aylesworths Office. Please send us your patient forms IN ADVANCE of your appointment in order to expedite your appointment time. To send us your patient/insurance information, and review our privacy policy, fill out the form below. If you have any questions, please give us a call at 715-226-9232.

At your appointment time, please have your INSURANCE CARDS with you as well as any CO-PAYMENT that you might have with your insurance company. If you are unable to keep your appointment, please call our office as soon as possible, preferably 48 hours prior to your appointment.

Name:

City, State, and Zip:

Home Address:

City, State, and Zip:

Primary Phone:

Secondary Phone:

Work Phone:

Race:

White Native American African American Asian

Or, Specify:

Ethnicity:

Non-Hispanic/Non-Latino Hispanic or Latino

Or, Specify:

Language:

English

Or, Specify:

Drug Allergy:

Email Address:

How Would You Like to Be Contacted?

Mail Telephone Email Portal

How Would You Like Appointment Reminders?

Telephone Email Text Message

Date of Birth:

Age:

Social Security Number:

Check One:

Single Married Divorced Widowed

Check One:

Male Female

Were your reffered by another health care provider:

Yes No

If yes, then please name:

Primary Care Provider:

PRIMARY INSURANCE NAME:

SECONDARY INSURANCE NAME:

Please note that we are not a part of any Medicaid plans. Please check with your individual plan to make sure we are a participating provider.

MEDICAL HISTORY INFORMATION

Personal Medical History:

None Pre-Cancer (Actinic Keratosis) Acne Eczema

List of Body Location and Date of Skin Cancers:

Basal Cell Carcinoma:

Squamous Cell Carcinoma:

Melanoma:

Check All Current Medical Conditions:

Arthritis Asthma Cirrhosis Defibrillator Diabetes Glaucoma Gout Hay Fever Hepatitis High Blood Pressure High Cholesterol HIV Hypothyroidism Jaundice Pacemaker Tuberculosis Inflammatory Bowel

Pregnant:

Cancer:

Transplant:

Other:

Alcohol:

Tobacco:

Never Smoked Former Smoker Current Smoker (Everyday or Some Days)

Family History of Skin Problems.
Please List Family Member (father, mother, brother, sister)

Basal Cell/Squamous Cell Carcinoma:

Melanoma:

Pre-Cancer (actinic keratosis):

Acne:

Eczema:

Psoriasis:

Lupus:

Medications:

Preferred Pharmacy:

Permission to discuss and release information (please check all that apply***):

Leave a message regarding appointment or need to contact on home answering machine/cell Leave a message regarding appointment or need to contact on work phone Share confidential information with spouse Share confidential information with children Share confidential information with parents (if over 18)

Any Special requests or information?

Upload attachment:

ACKNOWLEDGEMENTS OF NOTICE OF PRIVACY PRACTICES
I hereby acknowledge that I have reviewed the Notice of Privacy Practices describing the privacy practices and safeguards as well as my rights with respect to my protected health information maintained and used by Aylesworth Dermatology, SC.

AUTHORIZATION TO RELEASE INFORMATION
I hereby authorize Aylesworth Dermatology, SC to release to the Health Care Financing Administration and its agents (Medicare), Insurance companies or Third parties any information needed to determine benefits payable for related services.

ASSIGNMENT OF BENEFITS
I request that authorized Medicare and/or Insurance payments of medical benefits be made to Aylesworth Dermatology, SC.

GUARANTOR RESPONSIBILITY
I understand that I am ultimately responsible for payment of any and all charges for medical services rendered by Aylesworth Dermatology, SC and if this assignment is rejected, modified, or not paid within a reasonable time after it has been filed, it will be my responsibility to pay any unpaid charges in full. If it is necessary to collect unpaid fees for services rendered, I agree to pay the charge assessed by the collection agency, legal counsel or court.

By checking, I certify that I have read and agree to the terms stated above.

PATIENT or LEGAL GUARDIAN's Name:

DATE:

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715-226-9232

Fax: 949-862-7646
550 E Timber Drive, Ste 1 Rhinelander, WI 54501

Home
About
Services
- Medical Services
- Cosmetic Services
Contact
- Patient Forms
- Make a Payment

Home
About
Services
- Medical Services
- Cosmetic Services
Contact
- Patient Forms
- Make a Payment

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