The following patient registration forms can be downloaded to your computer and printed at home. In order for Dr. Wise to provide a complete and comprehensive medical opinion it is important that she review all your medical information. Please be prepared to provide this information to our office along with your current medical insurance card and photo I.D. Below is a link to our patient registration forms for your hair consult. Please understand though we will submit your visit for coverage to your insurance company, some policies will not cover visits for the most common forms of hair loss and you will be responsible for the cost of the consult. If you have any questions about these forms, our staff will assist you with your questions on the day of your visit.
Patient Registration Forms
HIPAA – Notice of Privacy Practices
Insurance Information Form
Please note, the following forms are only for patients scheduled specifically for a hair loss consultation with Dr. Emily Wise. Because of their time consuming nature, hair loss evaluations are not performed during skin exams or visits for other dermatology issues.
Intake form for Hair Loss
Hair Consult Billing Policy
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If you do not have a copy of Acrobat Reader you can get one for free by clicking on the icon ‘Get Acrobat® Reader’. This will take you to Adobe’s website and enable you to download the Acrobat program to your computer.