patient forms


Administrative Staff: Krista Kiefer, Janene Seemuth, Marlene Swaim, Virginia Bontrager, Sue Gingerich




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 our service.  Cosmetic procedures are to be prepaid in full as insurance does not cover these procedures.  For your convenience we accept Visa, Mastercard and Discover, in addition to cash and checks.  If we are not contracted with your insurance carrier, we will still file the insurance forms. 










-Completed Medical History form
-Completed New Patient Registration
-Insurance card (please bring to each visit)
-Photo ID if 18 or older
-Treatment of Minors form if under 18
-Completed referral (pre-authorization) form, if your medical insurance plan requires
-Medical Records Release page 1
-Medical Records Release page 2







Your provider will review your medical history and the symptoms that prompted your visit. Your provider will then perform a clinical exam of your skin. When scheduling your appointment 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, time permitting. Due to the time required, surgical excisions will usually be scheduled for a second visit.