Dermatology Associates of the South Bay
20911 Earl Street Suite 310
Torrance, CA 90503
NEW PATIENT REGISTRATION
Date: ______________________
PATIENT INFORMATION 
Last Name: ____________________    First Name: _____________________    M.I.: ________      Sex:  M / F
 
Birth Date: ______/______/_______         Age: ________      Social Security #: __________-_________-_________
Address: ______________________________________________________________________________________ 
                          Street                                         City                                     State                               Zip
 
Phone: Home: (           )                                  Cell: (          )                                      Work: (          )
Which is the best number to contact you during business hours? 
Occupation: _____________________________________   Employer: ____________________________________
EMERGENCY CONTACT INFORMATION
Name of friend or relative (not living at the same address) ____________________________________ 
Home phone: ___________________________    Cell or Work Phone: _________________________
 
Do we have permission to:

Leave a message on your answering machine?
Leave a message on your cell phone?
Leave a message at work?
Discuss your medical condition with anyone?
If yes please give name: ____________________________
 


Yes / No (Please Circle)
Yes / No (Please Circle)
Yes / No (Please Circle)
Yes / No (Please Circle)
Chose Dr. Kyle because/Referred to Dr. Kyle by: ____________________________________________
(Please check one): 
__ Doctor                        __ Insurance Plan              __ Family Member       __ Friend         
__ Yellow Pages              __ Internet                         __ Other: _________________________________
INSURANCE INFORMATION 
Subscribers Name: ______________________________  Subscribers Birthdate: _______/_______/_______
Relationship to Subscriber (Circle):  Self  /  Spouse  / Child  /  Other
Primary Insurance Policy Name: Secondary Insurance Policy Name: 
Group Number:                  Policy Number:                           Group Number:                   Policy Number:
I authorize my insurance benefits to be paid directly to the physician. I understand that I am financially responsible for the services provided. I also authorize Dermatology Associatest of the South Bay, or my insurance company to release any information required to process my claim. 
Patient / Guardian Signature: _______________________________      Date: _____/_____/_____