Patient Forms

 Patient Registration  |  Consent to Treat Minors  |  Mohs/Surgical History Form  |  MoleWatch Map

PATIENT REGISTRATION

Patients who are new to Midwest Dermatology Clinic, or who have not been seen within the past 12 months, must complete and sign a Patient Registration form. In addition, the Authorization to Release Form must be signed as indicated.

To make check-in quicker and easier, click on the links below to bring up a PDF version of the forms. You can type directly on the Registration and Medical History form. By completing this form on your computer, you will prevent legibility concerns and ensure that correct information will be used by our office to store your medical record and file insurance claims.

Use the following instructions to complete these forms:

 

  1. Patients seeing Dr. Luckasen:
    Click here
    Please complete the Registration and History Form, print all pages, sign as indicated and bring with you to your appointment.
  2. For Dr. Papenfuss, Dr. Madson or Dr. Darling:
    Click here
    Please complete the Registration Form and History and Intake Form, print all pages, sign as indicated and bring with you to your appointment.

NORFOLK PATIENTS ONLY:  Patient forms may be faxed to our Norfolk office prior to your appointment to speed up your check in time.  Simply print out all forms after filling in the blanks, sign as indicated and fax to (402) 371-4677.

 

CONSENT TO TREAT MINORS FORM

In order to provide medical services, treatments, and/or procedures for minors, the Consent to Treat Minors form must be completed prior to the scheduled appointment.

Use the following instructions to complete this form:

  1. Click on the link for the Consent to Treat Minors Form to open.
  2. Print out the completed form.
  3. Complete the form in its entirety.
  4. Bring to the office on the day of your appointment

MOHS/SURGICAL MEDICAL HISTORY FORM

Patients undergoing Mohs Microscopic Skin Cancer Surgery, or other surgical procedures as directed by your Midwest Dermatology Clinic physician, must complete and submit a medical history form prior to the procedure.

Use the following instructions to complete this form:

  1. Click on the link for the Mohs/Surgical Medical History Form to open.
  2. Complete the form in its entirety (you can type directly on the form).
  3. Print out the completed form and bring to the office on the day of your appointment

MOLEWATCH MAP AND POLICY

Please fill out our Molewatch Map. You will be contacted for an appointment at the office most convenient to you. Molewatch is an initial screening and cannot be substituted for an annual skin examination.

NOTICE OF MOLEWATCH POLICY, MIDWEST DERMATOLOGY CLINIC, P.C.

This Molewatch offer is for the free examination and evaluation of moles only. Examination and treatment of any other skin condition is not covered by the molewatch offer and will be charged to the patient in the customary manner. At the Molewatch appointment, the physician will examine your moles for warning signs of skin cancer. After examining your moles, the physician has completed your Molewatch exam and you will be informed of the findings and recommendations. At that point, the Molewatch service will be complete and there will be no office visit charge for your Molewatch examination.

Your doctor may recommend further testing or removal of a lesion. This cost is not included in the Molewatch offer and will be charged to you. In many cases, the cost is reimbursed by health insurance. If extended time is needed to perform the procedure, you may be asked to return to the office at a later date. Molewatch examinations are intended to assist in diagnosis and medical care of untreated skin cancers and are not a substitute for routine follow-up care.