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  • Note: We do not offer phone or virtual consultations. All appointments are in person at our NYC based office.
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Home Patient Form

Patient Form

Please note – by filling out this form, your credit card will not be charged until we confirm an appointment time with you. Initial consultation fee of $650 is non refundable unless 48 hour written cancellation notice is provided.

Please Fill Out All Form Info Below

Name(Required)







Home Address(Required)



















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Pharmacy Info

Pharmacy Address


















Insurance Address



















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Business Address


















Emergency Contact Address


















Please Confirm all info

Please note that Dr. Green is not contracted with any insurance company. Please contact your individual insurance carrier to confirm what your individual out-of-network benefits are. The initial medical or cosmetic consultation fee is $650.00 – Initial consultation fee is non refundable unless 48 hour written cancellation notice is provided.

Following a medical consultation, you will be provided with a HICFA form that you can submit directly to your insurance company. For a medical consultation, your $650.00 consultation fee is not transferrable to any cosmetic or medical procedure. If your initial visit is cosmetic in nature, the initial consultation fee may be applied towards a cosmetic treatment within the first three months of your visit. The consultation fee is not, however, to be applied to any medical treatment or products available in the office.

The follow-up fee for a cosmetic treatment is dependent on the procedure performed during the visit. The follow-up fee for a medical visit is $400.00. Any additional medical procedure performed will be an additional charge.

If you have decided to have a complete skin examination, we would like you to be aware that for each mole removal there is a fee of $400. The mole is then sent to the laboratory for examination and you will receive a separate invoice from the pathology lab that is independent of our office.

The following list is a list of the laboratories and the insurances which they contract with. Our office sends Dermatology (biopsy results) to the Ackerman Academy and Blood/Cultures to Quest and LabCorp. If your health insurance does not cover these laboratories, you may choose a different lab to send your specimens to. Please make Dr. Green or her assistant aware of your choice at the time of your visit.

A 48-hour notice is required for cancellation otherwise patient is responsible for a $650 cancellation fee for new patients and $200 for existing patients. Payment is due when services are rendered and fees are non-refundable.

Consent(Required)

Questionnaire

Please confirm if you have any of the following
Liver disease or gall bladder disease(Required)


Duodenal or peptic ulcer(Required)


Lung disease(Required)


Other intestinal disease or colitis(Required)


Stroke(Required)


Heart disease(Required)


High blood pressure(Required)


Urinary or bladder problem or infection(Required)


Kidney disease(Required)


Venereal disease(Required)


Arthritis, joint problem, bone disease(Required)


Blood disorder or lymph gland disorder(Required)


Eye disease (glaucoma, cataract)(Required)


Thrombophlebitis(Required)


Frequent infections(Required)


Cancer(Required)


Neurological disorder(Required)


Emotional or psychiatric problem


Have you or any family members had Hay Fever?(Required)


Have you or any family members had Eczema?(Required)


Have you or any family members had Asthma?(Required)


Have you or any family members had Hives?(Required)


Have you or any family members had Diabetes?(Required)


Have you or any family members had Psoriasis?(Required)


Have you or any family members had Skin cancer?(Required)


Have you or any family members had Glaucoma?(Required)


Also include any allergies to medications
Have you had radiation?(Required)


Please include any types of moisturizers, sun-block, serum, acne treatment and topical medications.
Are you allergic to any medicines(Required)


For Women Only

Have you had vaginal yeast infections?


Are you pregnant?


Are you planning a pregnancy?


Note

Please inform Dr. Green at any time if you do plan to or become pregnant during your treatment period.
At the time of your first visit to this office, it is necessary for your entire skin to be examined. This will enable Dr. Green to see not only the particular skin condition for which you are consulting us, but also other skin problems of which you may not be aware.
You will be provided with a proper gown for your examination.
If for any reason you do not wish to have such a general examination of your skin, please tell Dr. Green and she will make a note on your chart regarding your wishes.

Doctor / Medical Contacts

Dear Patient, in order to help you keep your medical history up to date, please list all physicians you would like us to send your pathology and lab reports to.

Medical Contact 1: Address


















Medical Contact 2: Address


















Office Policy & Cancellations

It is our office policy to have 48 hour cancellation notice otherwise an office visit fee of $200.00 will apply for existing patients and $650 for first time patients. Missed appointments without notification will automatically be charged an office visit fee. Payment is expected at the time of visit and visits are non-refundable. After 90 days all outstanding bills will automatically be forwarded for collection. All bounced checks will incur a $20.00 fee. All unpaid balances will accrue a finance charge of 3% per month and a $3.00 billing charge. I hereby authorize Dr. Michele S. Green, M.D., P.C. to charge to the below account, any outstanding balance. In the event that fees are not paid as delineated above, I agree to pay any and all collection and/or attorney’s fees incurred.

Name on Card(Required)







Consent(Required)

Privacy Policy

Email Consent(Required)
Privacy Policy Consent(Required)

Medical Photography Consent Form

I consent to medical images and/or videos to be made of me. I agree that duplicates may be made for the referring doctor.
By signing this form below I confirm that this consent form has been explained to me in terms which I understand.
I consent for these photographs and/or videos to be used in medical publications, including medical journals, textbooks, and online/offline electronic publications. I understand that the image may be seen by members of the general public, in addition to scientists and medical researchers that regularly use these publications in their professional education. Although these photographs and/or videos will be used without identifying information such as my name, I understand that it is possible that someone may recognize me. I also agree for my image to be shown for teaching purposes and to be used for my medical record.

I agree that the images may be:

Placed in my medical record for future treatment(Required)


Electronically emailed to my treating health professional(Required)


Used by health professionals for education and training(Required)


Used in paper or electronic health publications(Required)


Used in commercial broadcast(Required)


Used in internet or for marketing(Required)


By signing below, I confirm that I understand this photo consent form.(Required)

Laboratory Informed Consent Form

There is no charge at the office of Dr. Michele Green to draw your blood. LabCorp will send you a bill for
any testing performed. The LabCorp fee will be dependent upon your insurance company and
deductible.
We are happy to provide you with a lab requisition form at your request should you prefer to have your
blood drawn at a lab of your choice
By signing below, I confirm that I understand this consent form.(Required)