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Welcome to Johnson Dermatology Clinic
Please fill out the details below for each step and then click Next to proceed
Account
Financial
Medical
Payment
Notices
Patient Photo:
Step 1 - 5
Take Photo
Pick Photo
Clear Photo
Personal Information:
First Name:
Middle Name:
Last Name:
Address:
City:
State:
<Select State>
AE - Military – Europe / Africa / Canada
AK - Alaska
AL - Alabama
AP - Armed Forces Pacific
AR - Arkansas
AS - American Samoa
AZ - Arizona
CA - California
CO - Colorado
CT - Connecticut
DC - District of Columbia
DE - Delaware
FL - Florida
GA - Georgia
GU - Guam
HI - Hawaii
IA - Iowa
ID - Idaho
IL - Illinois
IN - Indiana
KS - Kansas
KY - Kentucky
LA - Louisiana
MA - Massachusetts
MD - Maryland
ME - Maine
MI - Michigan
MN - Minnesota
MO - Missouri
MP - Northern Mariana Islands
MS - Mississippi
MT - Montana
NC - North Carolina
ND - North Dakota
NE - Nebraska
NH - New Hampshire
NJ - New Jersey
NM - New Mexico
NV - Nevada
NY - New York
OH - Ohio
OK - Oklahoma
OR - Oregon
PA - Pennsylvania
PR - Puerto Rico
RI - Rhode Island
SC - South Carolina
SD - South Dakota
TN - Tennessee
TX - Texas
UT - Utah
VA - Virginia
VI - Virgin Islands
VT - Vermont
WA - Washington
WI - Wisconsin
WV - West Virginia
WY - Wyoming
Postal:
Date of Birth:
Social Security:
Gender:
<Select Gender>
Male
Female
Unspecified
Ethnicity:
<Select Ethnicity>
Non-Hispanic or Non-Latino
Hispanic or Latino
Withheld
Race:
<Select Race>
American Indian or Alaskan Native
Asian
Asian
Black
Black or African American
Caucasian
Declined to Specify
Hispanic
Native American
Native Hawaiian or other Pacific Islander
Other
Other Race
White
Marital Status:
<Select Status>
Single
Married
Widowed
Divorced
Other
Contact Information:
Mobile Phone:
Home Phone:
By submitting your phone number, you are authorizing us (opting in) to send you text messages and notifications. Message/data rates apply. Reply STOP to unsubscribe to a message sent from us.
Work Phone:
Email Address:
Emergency Contact:
First Name:
Middle Name:
Last Name:
Mobile Phone:
Relationship:
<Select Relationship>
acquaintance
aunt
brother
brother-in-law
cousin
daughter
daughter-in-law
father
foster daughter
FOSTER MOTHER
foster son
granddaughter
grandfather
grandmother
grandson
guarantor
guardian
husband
mate
mother
Mother-in-law
nephew
niece
other
sister
sister-in-law
son
stepbrother
stepdaughter
stepfather
stepmother
stepsister
stepson
uncle
unknown
wife
Driver License:
For Best Results
Hold your driver license as close to the camera as possible until your camera focuses properly on the license. We just need to be able to see the details clearly.
Front:
Take Photo
Pick Photo
Clear Photo
Back:
Take Photo
Pick Photo
Clear Photo
Employer Details:
Employment Status:
<Select Status>
Employed
Part Time Student
Full Time Student
Retired
Seasonal Worker
Migratory Worker
Other
Employer
Occupation
Address:
City:
State:
<Select State>
AE - Military – Europe / Africa / Canada
AK - Alaska
AL - Alabama
AP - Armed Forces Pacific
AR - Arkansas
AS - American Samoa
AZ - Arizona
CA - California
CO - Colorado
CT - Connecticut
DC - District of Columbia
DE - Delaware
FL - Florida
GA - Georgia
GU - Guam
HI - Hawaii
IA - Iowa
ID - Idaho
IL - Illinois
IN - Indiana
KS - Kansas
KY - Kentucky
LA - Louisiana
MA - Massachusetts
MD - Maryland
ME - Maine
MI - Michigan
MN - Minnesota
MO - Missouri
MP - Northern Mariana Islands
MS - Mississippi
MT - Montana
NC - North Carolina
ND - North Dakota
NE - Nebraska
NH - New Hampshire
NJ - New Jersey
NM - New Mexico
NV - Nevada
NY - New York
OH - Ohio
OK - Oklahoma
OR - Oregon
PA - Pennsylvania
PR - Puerto Rico
RI - Rhode Island
SC - South Carolina
SD - South Dakota
TN - Tennessee
TX - Texas
UT - Utah
VA - Virginia
VI - Virgin Islands
VT - Vermont
WA - Washington
WI - Wisconsin
WV - West Virginia
WY - Wyoming
Postal:
Employer Phone:
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