Mailing Address: Name: FIRST MIDDLE LAST. Mailing address: If different from patient. Telephone Numbers: Home Day Number

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Logan Cummings
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1 Dermatology Center South PC 2800 Ross Clark Circle, Suite 2 DOTHAN, ALABAMA REGISTRATION FORM FOR DEPENDENTS] Patietnt Name: First Middle Initial Last of Birth: / / Sex: Male Female Month Day Year Mailing Address: Home Telephone Number: Student Status: Full Time Student Part-time Student How do you want to be notified of future appointments? Text Phone PARENT/LEGAL GUARDIAN INFORMATION Payment Policy The adult/guardian who brings in child will be responsible for all copays and deductibles. We do not forward bills to other parties regardless of court rulings or divorce degrees. If requested, a receipt will be issued at the time of payment for your use. Please complete the following with your information. Name: FIRST MIDDLE LAST of Birth: / / mo day year Social Security Number Mailing address: If different from patient Telephone Numbers: Home Day Number INSURANCE INFORMATION PLEASE GIVE INFORMATION OF THE PERSON WHOSE NAME IS ON THE CARD PLEASE PRESENT YOUR INSURANCE CARD AND PICTURE ID TO THE RECEPTIONIST Name of Primary Insurance Company: Name of Insured: of Birth / / First Middle Last Address of Insured: Phone # if different from patient Street City State Zip Code Is the insured employed? YES NO or RETIRED Name of Secondary Insurance Company: Name of Insured: of Birth / / First Middle Last Address of Insured: Phone # if different from patient Street City State Zip Code Is the insured employed? YES NO or RETIRED If I have a balance due today, I will pay with cash check credit card (Visa, MasterCard or Discover)

2 Parent/Legal Guardian Signature 2800 Ross Clark Circle, Suite 2 Dothan, AL Authorization for Verbal Release of Protected Health Information Standard Disclosure: I authorize Dermatology Center South PC to discuss my medical history, diagnosis, treatment, prognosis, and financial, insurance and billing information with those listed below. I understand this may include information regarding testing, examination, and treatment for HIV, AIDS related illness, mental health and drug, alcohol or chemical abuse, as well as, confirmation of any appointment for me to be seen in the office, hospital or other physician s office. Spouse: Children: Parent(s): Other: NO INFORMATION I do not authorize the release of any verbal information concerning my treatment, I understand that this includes confirmation of dates, times, locations, and any billing or financial information. I consent and authorize the release of any test results to be left on my voice mail at: Home Work Other This authorization will expire at the end of my treatment with Dermatology Center South PC unless I revoke this consent prior to that time. Signature of Patient Witness Patient Acknowledgment and Consent

3 I have been given a copy of Dermatology Center South s Notice of Privacy Practices, version effective December 4, I consent to the uses and disclosures of my health information as outlined in the Notice. Signature of Patient Printed Name of Patient Medical Record Number Signature of Parent or Legal Guardian/Representative Printed Name of Parent or Legal Guardian/Representative Documentation of Failure to Obtain Signed Acknowledgement: On I _an employee of Dermatology Center South PC presented this Acknowledgement of Receipt of Notice of Privacy Practices form to patient. The patient refused to provide a signature when requested. eprescribing Consent eprescribing is a federally mandated initiative that requires all physicians to prescribe in this manner. eprescribing software sends prescriptions over the internet to your pharmacy in a safe, secure way, utilizing secure technology to protect the privacy of your personal information. eprescribing software also allows us to see important information such as drug interactions and your prescription history. The benefit to you is less confusion over handwritten prescriptions or unclear phone calls, reduced possibility of medical errors, fewer trips to drop off prescriptions at the pharmacy, and a safer, faster, easier way to get your prescription filled. Patient Signature Patient Name of birth Primary Care Physician Medical History Anemia (low blood count) Lupus

4 Anxiety Mental health issues Arthritis Seasonal allergies Asthma Seizures Blood clotting disorder Blood clots (deep venous thrombosus, pulmonary embolus) Cancer (what type?) Coronary Artery Disease Stroke Depression Diabetes Hyper-thyroid disorder Easy bruising Hypo-thyroid disorder Easy scarring/keloid Kidney problems (renal disorder) Hayfever Heartburn/Reflux (GERD) Irregular heartbeat (atrial fibrillation) Heart Valve Problems HIV/AIDS Hepatitis High blood pressure (hypertension) HIV/AIDS High cholesterol (hypercholesterolemia) Past Major Surgeries (incl. joint replacements, organ transplants, pacemakers) Do you require antibiotics before dental cleanings or surgical procedures due to a history of heart valve replacements, joint replacement, rheumatic/scarlet fever? YES NO

5 Skin Disease History Precancers Squamous Cell Carcinoma Eczema/Dermatitis Basal Cell Carcinoma Melanoma Psoriasis Sensitive Skin Medication Allergies Medications (Names only) Vaccinations: Have you had? Pneumonia: YES NO If yes, what was the date of last shot? Flu: YES NO If yes, when was the date of last shot? Family History: (Mom, Dad, brothers, sisters only not aunts/uncles, etc) Melanoma Breast Cancer Social History:

6 Alcohol use (if yes, how many drinks per day?) Tobacco use Never smoked Smoke now (how much?) Quit smoking (when?) Occupation/Workplace: Language Spoken Circle one: Race: White, Hispanic, Black or African American, Other Ethnicity: NOT Hispanic or Latino Hispanic or Latino PHARMACY: Name Address City State

2800 Ross Clark Circle, Suite 2 Dothan, AL

2800 Ross Clark Circle, Suite 2 Dothan, AL 36301 334-677-1690 Minor Patient Registration Form First Name M.I. Last Name Preferred Name: Street Address: Apt, Lot, Suite # City: State: Zip: DOB: Age: Sex: