Please complete the following confidential information. *First Name *Last Name *Date of Birth *Insurance Company *What procedure are you interested in? Repair of Torn Earlobe  Removal of Keloid  Removal of Mole We must be able to contact you. Please complete the following: *Telephone # Other Telephone # Fax # Email Address Apt # City State *Insurance ID # *Insurance Group *Insurance Carrier Tel # Please allow 24 hours for your insurance to be approved. We also need to be able to contact you to let you know you are approved. Any of the following would be fine: e-mail address, daytime telephone number. If you prefer, you may contact us 24 hour after submitting your information by e-mail or telephone. We want our prospective patients to feel as comfortable as possible while getting to know us.

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