Moore Unique Dermatology & Spa
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(713) 741-33762525 W Bellfort Ave #105 Houston, TX 77054
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Unique Dermatology and Spa
Unique Dermatology and Spa
  • Home
  • Services
    • Dermatology
    • Cosmetic Surgery
  • Appointment
    • Returning Patient
    • New Patient
    • Pay Online
  • Products
  • Contact
  • Moore Relief
Schedule Appointment
  • Home
  • Services
    • Dermatology
    • Cosmetic Surgery
  • Appointment
    • Returning Patient
    • New Patient
    • Pay Online
  • Products
  • Contact
  • Moore Relief

New Patient

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  2. Appointment
  3. New Patient
Fields marked with an * are required
If you have not had an appointment in more than 2 years you are considered a new returning patient.

"*" indicates required fields

Patient Name*
Gender*
MM slash DD slash YYYY
Address*

Pharmacy Information

Address*

Employer Information

Emergency Contact Information

Emergency Contact Name*

Insurance Information

MM slash DD slash YYYY
Health Savings and/or Deductible Met

Secondary Insurance Information

Please Note: We will file your claim with your Secondary Insurance company, but you are responsible for paying the secondary amount. However, you will get a refund once the secondary insurance company pays.
MM slash DD slash YYYY

Drivers License & Insurance Card

Please upload an image of your Drivers License and Insurance Card (front and back of each)
Drop files here or
Accepted file types: jpg, gif, png, Max. file size: 15 MB, Max. files: 4.

    Medical History

    Please check all that Apply*
    Are you allergic to any of the following?*
    Please check all that apply
    Do you have any of the Following?*
    Please check all that apply
    Are any of the following in your past medical history?*
    Please check all that apply
    Are any of the following in your past medical history?*
    Please check all that apply
    Please check all that Apply
    You will be contacted within 48 hours to confirm your exact appointment time & day.
    MM slash DD slash YYYY
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