Mosaic Dermatology Houston
MCDermatology.com
 


First Time Patients - Complete This Form To Minimize Wait Time And Improve Patient Care.  
Return patients only need to do this if you are here for a new problem.  If you are only sending updated insurance you can use the other button on our website.


Tell Us About You:
 
First Name
Last Name
Cell Phone
Name of preferred pharmacy. Choose
one you would use near work or home.

 
Pharmacy Address As It Appears Online.
Date of Birth (mm/dd/yy)
 
Your Exact Mailing Address
 

Send Us Stuff:

Front of Insurance card (if using insurance and you are new to the clinic - we need this in advance).
 

Back of Insurance card - if using insurance. (we need both sides in advance or we can not check you in).
You can bring a hard copy on the day of the visit but we do not take electronic copies or pictures of insurance on check in.




Please Read The Clinic Policies Carefully:
 
The clinic has a same day no show, or same day cancellation, fee of 35$ and being 15 minutes late means you will not be seen and counted as a no show.  Any rescheduling or changes made without advance norice 1 business day before - by 2pm - will count as a no show for your original spot.  (Please Type: I Agree)

 
I understand the clinic does not accept insurance cards marked with Medicare, Medicaid, Molina,  "Select" plans, Navigation, Community, Memorial Hermann, Star plans, or HMO* plans. Please look at your card carefully in advance as these are written on the insurance card itself.   We do NOT take medicare even with a secondary.  We can not take self pay or cash pay for medical visits if you have have any Medicare plan unless this is a cosmetic visit i.e Fillers, Botox, ect.   If you are in the above categories please call us so we can help you find a clinic. (Please Type: I Agree).  
 
The clinic requires Mastercard or Visa for any payments and does not accept cash or American Express. FLEX or HSA are accepted for medical visits, but not for cosmetics, per federal rules. (Please Type: I Agree)
 
The clinic requires a physical hard copy of your insurance card. We can not accept insurance card pictures on smart phones unless they are uploaded front/back 1 business day in advance and via our website.  Please do it in advance, if you do not have a hard copy. (Please Type: I Agree)
.
If you are insured, your co-pay can cover your basic medical visit completely.  However, IF

1) Your visit involves a procedure and/or is more than a basic consultation and prescription OR,
2) You have any medical procedure, freezing, or biopsy done during the visit OR
3) You have an insurance plan that requires a deducitble be met before insurance kicks in THEN

Please note, like most dermatology clinics dealing with complex insurance, we will file insurance after the visit.  While we await insurance's written response, only a partial payment is collected during the visit date.  Please watch for mailings from your insurance with details on final coverage as they may decide more of the bill is the patient's responsiblity(Insurance takes weeks to decide & finalize). This may mean you could get a bill from the clinic and a seperate bill from the lab.  In some cases, you may get a refund from the clinic.  (Please Type: I Agree)

Current Medical Issue:
Main Reason For Visit 
Location Of The Problem
Have Had This For (Days/Weeks/Months/Years)
Symptoms (itch/burn/bleed/pain/color change)
Currently? (Stable or Getting Worse)
Prescriptions Tried?
Which Prescription (if any) Helped?
And What Else Do You Need To Telll Us.
Please Include Details And Organize Your Thoughts Here.  
 
 
History of Basal or Squamous Cell Cancer?
History of Melanoma?
  
 
Second Reason For Visit (CC)
Location Of The Problem
Have Had This For (Days/Weeks/Months/Years)
Symptoms (itch/burn/bleed/pain/color change)
Currently? (Stable or Getting Worse)
Prescriptions Tried?
Which Prescription (if any) Helped?
And What Else Do You Need To Telll Us.
Please Include Details And Organize Your Thoughts Here. 
 
 

Past Medical History (Type: Yes or No)
Diabetes?
Hypertension?
Other:

 
Family Medical History (Type: Yes or No)
 
Immediate Family History Of Skin Cancer and Which Type Of Skin Cancer?

Social History (Type: Yes or No)
 
Smoke?
Drink Alcohol?


Current Prescription Medications 
 
Names of PRESCRIPTION medications you are on(if any)?


 Allergies
 
What PRESCRIPTION Medications Are You Allergic To(if any)?


Top 4 FAQ

1 - Does the clinic treat Hair Loss or Alopecia?

Sorry, no we do not, but we do prescribe the male hair loss pill - Propecia/Finasteride.  We also do treat and manage scalp skin conditions. 

2 - Does the clinic treat Keloids?

Sorry, we do not treat keloids.

3 - Does the clinic prescribe Accutane/Isotretinoin or Biologics like Enbrel or treat Urticaria and Hives?

Sorry, we do not.

We treat almost all skin related conditions, however we do not treat the above

4 - If I need to cancel, how do I avoid a no show or last minute cancellation fee?


We would need to hear from you 1 business day in advance by 2pm.  Please find more details here.


5 Our full HIPAA and clinic policy form is located at the bottom of our main website page, and is available upon request.  
 

All Done?  Last Step Is To Click Submit Form