Patient Information & Forms

Patient Forms

New Patient Registration Medical History Treatment of Minors

Welcome to Town Square Dermatology!

Our mission is to provide the finest dermatologic care possible in addition to maintaining a relaxed and friendly environment. To that end we have compiled the following information to make your first and subsequent visits as rewarding and stress-free as possible.

Office Location: 1100 6th Street, Suite 202 Coralville, IA 52241 319-337-4566

Office Hours: Our office hours are 8:00 am to 5:00 pm Monday through Friday.

Should you have an after hours emergency call 319-339-0300.
The Mercy Hospital operator will connect you to the on call dermatologist.

What to bring to your first visit:

• Your completed Medical History Form (download from our web site) (Please bring your updated medication list to each visit)
• Your completed New Patient Registration Form (download from our web site)
• Your insurance card (Please bring to each visit)
• Your Completed Referral (Preauthorization) Form, if your medical insurance plan requires one

What to expect during your first visit:

Your provider will review your medical history and the symptoms that prompted your visit. She will then perform a clinical exam of your skin. Please feel free to request a complete skin examination if desired. If a procedure is required for diagnosis or treatment of a skin condition it will often be performed at your first visit. Due to the time required, surgical excisions will usually be scheduled for a second visit.

Financial Policies:

We participate in most insurance and managed care plans. We will file insurance forms as a service to the patient. Payment of co-pays and deductibles are due at the time of service. Cosmetic procedures are to be prepaid in full as insurance does not cover these procedures. For your convenience we accept Visa, Mastercard, Discover and American Express, in addition to cash and checks. If we are not contracted with your insurance carrier we will still file the insurance forms as a service to you, however we will expect payment of 25% of the account balance at the time of service.

Referrals:

If another healthcare provider has arranged for your appointment please be aware that we will report our findings and recommendations to that provider unless you specifically request otherwise. If your medical insurance plan requires you to have a referral form from your primary care physician in order to see a specialist, please be certain to obtain this before your scheduled appointment. In certain circumstances, failure to bring the form with you will require rescheduling of the appointment.

Prescription Renewals:

Prescriptions and refills are issued during office hours. To have your prescriptions refilled, please have your pharmacist call or fax our office. Some prescription medications require monitoring and patients may be asked to make an appointment prior to receiving refills.

If you cannot keep a scheduled appointment, we request that you reschedule or cancel at least 24 hours in advance by calling 319-337-4566.