New to NicholsMD

Fill out our new patient paperwork below!

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New Patient Paperwork
Today's Date
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Full Name
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How May We Address You? (i.e nickname)
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Age
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Date-of-birth
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Gender
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Email
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Mailing Address
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City
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State
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Zip
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Home Phone
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Cell Phone
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Occupation
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Employer
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Emergency Contact

Emergency Contact Full Name
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Emergency Contact Phone
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Emergency Contact Relationship
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Pharmacy

Name
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City/State
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Phone Number
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Parent/Responsible Party (if different from Patient)

Full Name
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Relationship to Patient
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Home Phone
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Cell Phone
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Email Address
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Whom Do We Have the Pleasure of Thanking for Refering You? (Person)
List Name(s) of Referral Person
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Whom Do We Have the Pleasure of Thanking for Refering You? (Magazine)
Whom Do We Have the Pleasure of Thanking for Refering You? (Online)Please check all that apply:
Other Referral (Please Explain)
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Another Physician's Office? (Name of Physician)
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MEDICAL HISTORY

Do You Have Any Allergies To Medication?pick one!
If Yes, Please List The Names Of The Medications You Are Allergic To:
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Please List Any Medical Conditions You Have:
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Please List Any Medications You Currently Use:(Include Over-The-Counter And Topical Medications, Vitamins And Herbal Supplements)
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Do You Have A History Of Skin Cancer Or Another Severe Skin Condition?pick one!
If So, Please Describe:
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Do Any Close Family Members Have A History Of Skin Cancer Or A Severe Skin Disease?pick one!
If So, Please Describe:
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Do Any Close Family Members Have A History Of Skin Cancer Or A Severe Skin Disease?

pick one!

Do Any Close Family Members Have A History Of Skin Cancer Or A Severe Skin Disease?

An annual full-body skin examination to screen for skin cancer is recommended. There is no additional charge for this exam over the initial office visit charge. The exam is performed with a gown and undergarments on. Would you like this exam performed?pick one!

COSMETIC QUESTIONNAIRE

SkinCeuticals SkinLab has a curated menu for selective luxury services in under an hour.  Below is our full menu of services, available at NicholsMD of Greenwich. For our entire Before and After Gallery.

Specific Areas of Concern
If Other Specific Areas of Concern
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Notable Procedures of Interest
If Other Specific Areas of Concern
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NOTICE OF PRIVACY PRACTICES CONSENT

Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. The Notice contains a Patient Rights section describing your rights under the law. You have the right to review our Notice before signing this Consent. The terms of our Notice may change. If we change our Notice, you may obtain a revised copy by contacting our office.

You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment, or health care operations. We are not required to agree to this restriction, but if we do, we shall honor that agreement.

By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment and health care operations. You have the right to revoke this Consent, in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior Consent. The Practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

The Patient Understands That:

  • Protected health information may be disclosed or used for treatment, payment, or health care operations
  • The Practice has a Notice of Privacy Practices and that the patient has the opportunity to review this Notice
  • The Practice reserves the right to change the Notice of Privacy Practices
  • The Patient has the right to restrict the uses of their information but the Practice does not have to agree to those restrictions
  • The Patient may revoke this Consent in writing at any time and all future disclosures will then cease
  • The Patient may condition receipt of treatment upon the execution of this
  • Authorization, Assignment And Acknowledgment

    My signature below indicates that I have read and understand this consent in its entirety, that my questions have been adequately answered, and that a copy of the Notice of Privacy Practices is available to me upon my request.

    Please Check for Authorization
    Today's Dateof appointment
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    PHOTOGRAPHY RELEASE FORM

    I understand that taking medical photographs is an important part of patient care. Thus, I authorize NicholsMD of Greenwich, Dr. Kim Nichols and staff representatives, to take photographs of my body for medical purposes. These photographs will ONLY be used for my patient care.

    Please Check for Photography Release
    Today's Dateof appointment
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    FINANCIAL POLICY AT NICHOLSMD

    Financial Policy

    Payment is due in full at the time of service for consultations, examinations, and procedures. We accept cash, checks, and all major credit cards. As a courtesy, we also offer Care Credit™, a credit card financing program for cosmetic procedures. Please ask for more information if you are interested.

    Our office will keep your credit card on file in order to expedite checkout transactions, charge non-refundable deposits towards specific appointments, and/or cancellation etiquette breaches. 

    All consultation fees, follow-up appointment fees, deposits, and procedures done at SkinLab are considered services rendered, and thus, are non-refundable.

    Cancellation Etiquette

    SkinCeuticals SkinLab has a 24-hour cancellation policy. All appointments canceled less than 24 hours prior to the appointment will be charged $175, We also require non-refundable deposits for specific treatments and Saturday appointments.

    My signature below indicates that I am fully aware of the financial and cancellation policies of SkinCeuticals SkinLab, and I accept full responsibility for all expenses incurred. In addition, I grant authorization to release any information required to obtain payment of medical benefits.

    I have read and understand this statement in its entirety and my questions have been adequately answered.


    Authorization, Assignment and Acknowledgment

    By signing this document you have been made aware and agree to our financial and cancellation policies. 

    Please Check for Financial Authorization
    Today's Dateof appointment
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