Kingsport (423)246-4961 | Bristol (423)764-7131 | Johnson City (423)928-9014

Patient Registration Form

Welcome to Dermatology Associates Online Patient Registration System! Registering online with us is convenient and secure.

Your confidential information will be transferred securely over SSL (Secure Socket Layers) with 256 bit encryption. The lock in your browser indicates that your registration process is safe and secure.

Step 1 - Patient Registration Information

Required Field Indicates a required field.

Patient Information
Emergency Contact Information
Guarantor Information
(To Whom Statements are Sent)

Yes No ('No' Hides insurance information form fields below)

Primary Insurance Information
Policy Information
Policy Holder Information

Same as Guarantor?

Yes No (Hides secondary insurance information)

Secondary Insurance Information
Policy Information
Policy Holder Information

Same as Primary Insurance?

* Past Medical History

* Please check all that apply (If none of the choices below apply to you, check the 'NONE' box):

* Past Surgical History

Please check all that apply:

* Please check all that apply (If none of the choices below apply to you, check the 'NONE' box):

* Skin Disease History

Please check all that apply:

Social History:

Please check all that apply:

Cigarette Smoking:

Alcohol Use:

Skin Cancer Family History (Only first degree relatives)
Preferred Pharmacy Information:
Please check all that apply:
Confidential Communications

I authorize Dermatology Associates to share my health information with the individuals listed below. This authorization will remain in effect for one year unless I notify Dermatology Associates otherwise. Please Note: We encourage you to list all members of your household who you trust to give/receive medical information including pathology reports, appointment information or billing information, etc.

Persons Authorized


Assignment and Release:
  • I hereby assign my insurance benefits to be paid directly to the physician.
  • I understand that I am financially responsible for all non-covered services and any covered services not paid by insurance within 90 days.
  • I authorize the physician to release any information required to process this claim.
  • I understand that cell phone use and/or audio/video taping is prohibited in the clinical areas.
  • I give permission to DA to leave messages on my voice mail and/or to send text reminders to my mobile number
  • I understand that specimens obtained during my visit will be sent to an outside lab and may be billed separately.
  • I understand that the notice of privacy practices will be sent to my email address upon submission of this form.


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