(636) 561-3277

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    • Home
    • Our Providers
    • Services
    • Products
    • Patient Education
    • Patient Info & Forms
    • Contact Us

(636) 561-3277

  • Home
  • Our Providers
  • Services
  • Products
  • Patient Education
  • Patient Info & Forms
  • Contact Us

PATIENT INFORMATION & FORMS

FOR YOUR VISIT

A valid driver's license or photo I.D. and current insurance card must be presented at each office visit.


If you are a new patient, please arrive 15 minutes prior to your appointment to make time for the check-in process. Please bring a photo I.D. and insurance card, as well as a printed and completed New Patient Form (see below).


Automated reminder calls and/or text messages will be made three days prior to all appointments. Please respond to these messages as directed to confirm or cancel your appointment.



COPAYS

Copays and prior account balances must be paid prior to seeing the providers.



PARENT/LEGAL GUARDIAN

If you are under the age of 18, you will need to have a parent or legal guardian give consent for our physicians to see you. Print and fill out the Consent to Treat Minor form (below) to bring to your appointment. 



MEDICAL RECORDS

If at any point you would like to have your medical records from our office sent to another provider, please print the Medical Records Request form (below), fill out the necessary information, sign and give to the front desk staff after your appointment.



LATE NOTICE

A 24-hour notice of cancellation is required in order to avoid a $50 no-show fee. A $10 late fee is charged each month on any balances not paid once the monthly statement is received.

FORMS

Click to begin download. View in PDF Viewer and print. 

New_Patient_Forms (pdf)

Download

Consent_To_Treat_Minor (pdf)

Download

Medical_Records_Request (pdf)

Download

Copyright © 2022 O'Fallon Dermatology Specialists    (636) 561-3277 - All Rights Reserved.


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