Since we value your time as much as we value your skin, please review the following information prior to your visit so we can focus our time on your skin care needs. Completion of patient documents prior to arrival will expedite the check-in process. All forms are available in a fillable format by request and will be sent through your patient portal account. Please contact our front office staff to request an electronic version.

Patient Documents

Please print and complete all patient forms and include your name on every page as directed. Surgery patients, please return forms to us by mail prior to your appointment, unless otherwise advised. General dermatology patients, please bring completed forms to your appointment.

Please bring all insurance cards and photo identification on the day of your appointment.

Mohs Surgery Patient Paperwork

General Dermatology Patient Paperwork

Notice of Privacy and Nondiscrimination Practices

The Notice of Patient Privacy Practices and Notice of Nondiscrimination Practices are for your review and do not require printing, unless you would like a copy for your records.

Privacy Practices

Nondiscrimination Practices

Dayton Skin Care Specialists complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex.

Cancellation Policy

Please provide at least 72 hours notice if canceling a surgery to allow another patient the opportunity to fill your surgery date. Allow 48 hours cancellation notice if you need to reschedule a general dermatology appointment, follow up or full skin exam. Missing more than three appointments without providing at least 24-hour notice is grounds for discharge from the practice.

Insurance Plans

Your insurance coverage is an agreement between you and your insurance company. Financial responsibility rests with the patient for co-payments, deductibles, co-insurances and non-covered services. Insurance coverage is a variable and we cannot guarantee what services will be covered by your particular plan. If your insurance plan requires a referral from a primary care physician, you are responsible for obtaining the necessary referral. It is your responsibility to know the requirements of your insurance program. We will ask you to sign an authorization form requesting that insurance payments be sent directly to our office when appropriate.

We accept most insurance plans with a few exceptions. We are an out of network provider for Anthem Senior Advantage and all CareSouce plans. We may be out of network with some Medicaid and some employer plans. If you are uncertain, please check with your insurance plan.

United Healthcare Medicare Plans require pre-approval.

Please call our office to inquire if you have questions.

Co-Payments, Coinsurance, Deductibles And Outstanding Balances Are Due At The Time Of Service

All applicable co-payment, deductible and coinsurance and outstanding balances will be collected at time of service. Full payment is required for all non-covered services.

For your convenience, we accept personal checks, Visa, MasterCard, Discover, Care Credit and cash.

If you have any questions or concerns, please contact our billing department at 937-293-5567937-293-5567, option 4.

Nonpayment, Collection Costs and Returned Check Fee

Nonpayment of your account balance may result in transfer of collection efforts to an outside collection agency and credit damage. In the event your account is referred to a collection agency or attorney for collection, you will be responsible for all collection fees, attorney fees, court costs, and expenses. A $30.00 fee will be added to your account for each returned check.

Cosmetic Consults

There is no charge for cosmetic consults with our aesthetician. Patients who have a cosmetic consult with a physician will receive credit in the amount of the consult toward their cosmetic procedure, if scheduled and performed within 6 months.

Cosmetic Services Payment / Cancelation

Cosmetic Service and Laser patients will be required to make a $50 deposit at the time of scheduling. The deposit will be credited toward the service cost at your visit. We require 24 hour notice to cancel of reschedule your appointment. If you cancel with less than 24 hours notice or no-show for the appointment, you will forfeit your deposit. Deposits will not be refunded.

Sculptra requires a credit card on file and signed acknowledgement of financial policy at time of consult. Product must be constituted a number of days prior to injection, therefore we require 5 days notice to cancel or reschedule your appointment. Failure to provide a minimum of 5 days notice will result in a charge of $350 per vial to cover the cost of product loss.

Aesthetic, Cosmetic and Laser Service Packages

Package purchases must be paid in full at the time of scheduling. Refunds will only be made if requested prior to the first treatment. No refunds will be made following the first treatment, whether subsequent treatments are used or unused.

Retail Product Refunds

Dayton Skin Care Return Policy:
Unused/Unopened Product: 15 days from the purchase.
If you experience an adverse/allergic reaction, contact the office within five business days of purchase. Returns will be accepted at the physician’s discretion.
Clarisonic Returns: Contact Clarisonic Customer Service at 888-252-2742888-252-2742

Pathology and Lab Fees

Biopsies may be sent to a lab to be analyzed. The fee for this is a separate charge from the office visit. You may receive a bill from Dayton Skin Care Specialists for the physician service and a separate bill from the processing lab. Results are usually available 7-10 days after the test has been performed. Questions regarding payments for laboratory services should be discussed with the lab.

Schedule Changes

Please note that we try to accommodate everyone as quickly as possible. Patients with Melanoma will take precedence over other types of appointments. DSCS may call to move, reschedule or cancel your appointment based on the unpredictable nature of our business. Please understand that we are trying to meet the needs of our patients based on severity. We appreciate your understanding and cooperation if this occurs.