CHART # lease thoroughly complete this history form to help ensure the best possible medical treatment. Age:
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- Marlene McCormick
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1 % EDICAL HISTORY CHART # lease thoroughly complete this history form to help ensure the best possible medical treatment. atient: Age:.Today's : eason for visit: ow long have you had this problem? /hat treatment have you used on your own? /hat prescription treatments have been used? re you ALLERGIC TO ANY MEDICATIONS? If so, please list: ist any medications you are currently taking and circle the approximate length of time that you have been n the medication: \ ' ' 0 *lf you are taking more than 8 medications, please continue on the back ofthis form. iave you had aspirin or ibuprofen in the last two weeks? O yes iave you ever had dental anesthesia (novocaine? a yes O no fyes, any bad reactions? O no o you smoke? Dyes Ono If yes, how much? o you drink alcohol? yes a no If yes, how many drinks per day? o you use IV drugs? Dyes D no If yes, what kind? iaveyou ever had or been exposed to HIV (AIDS? D yes no iave you ever had or Deen exposed to Hepatitis? o yes o no When you are exposed tothe sun do you: Tan only O Tan and Burn D Burn Have you ever had skin cancer? O yes D no If yes, was it melanoma? Has a family member had skin cancer? O yes O no f yes, was it melanoma? O yes O no if yes, whom? Do you have a history of any specific skin diseases? O yes no f yes, please list the type:. Do you have artificial joints? Do you bleed easily? O yes Do you faint easily? _ yes Women Are you Pregnant? A/hat blood relative has: Diabetes Skin disease O yes O no no D no D yes (due date Asthma. What type? Do you have any of the following conditions? Diabetes Asthma Hay fever Lung disease Stomach ulcers»"&3p.mh «1 T510 TOREORDER CAUWHEALTH RECORD SYSTEMS BCO Dno Hay fever Heart disease.high blood pressure
2 Please Initial Each Line FINANCIALAGREEMENT 1. ^_J[understand payment is due at the time ofservice unless arrangements have been made in advance. Visa, MasterCard, Discover, and debit cards are accepted. 2. ;avm.f,, *auth0rize D,^y re Dermatology to file my insurance(s as acourtesy to me and understand payment for these services will be mailed directly to this office recognize that ultimate financial responsibility for my account remains mine Ifmy insurance company does not pay the practice within areasonable period, Iwill be responsible for the payment. If DeVore Dermatology receives acheck from my insurance company they will refund any overpayment in excess of $5.00. Overpayments under $5.00 will show as acredit on my account understand that not all insurance plans cover all services. In the event my insurance plan determines aservice to be "not covered" Iwill be responsible for the complete charge. Ihereby guarantee payment in full ofany and all charges for services rendered not covered by any health insurance plan includingall deductible and coinsurance amounts. 5. 1understand that acopayment or coinsurance is required at the time ofmy visit. 6. All balances due after insurance must be paid in 60 days unless awritten arrangement has been made. 7. As acourtesy to others and to avoid a$40 service charge, we kindly ask that you give a2 business day cancellation notice. We realize emergencies do arise and we will handle those on acase by case basis. 8-1am aware that there may be a$10 administrative charge for phoning in prescriptions and a $25 administrative charge to complete any miscellaneous forms. 9- We now request adebit, credit or health savings card on file for all accounts. Any amount the insurance states is your responsibility will be applied to the card on file. We do not send out bills for these balances. Use your EOB from your insurance company to show you what your responsibility would be. Patient Signature (or parent if a minor Print Name Ifyou are not the patient, please state your relationship MEDICARE PATIENTS ONLY: STATEMENT TO ASSIGN MEDICARE BENEFITS TO PHYSICIAN OR SUPPLIER Patient's Name: Medicare Number: "I request that payment ofauthorized Medicare Benefits be made on my behalfto DeVore Dermatology, P.A. for any services furnished to me by my physician. I authorize any holder ofmedical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits or the benefits payable for related services." Signature STATEMENT TO ASSIGN MEDIGAP BENEFITS TO PHYSICIAN OR SUPPLIER (SUPPLEMENTAL "I authorize Medicare to file my supplemental (Medigap insurance. I request that payment be made to DeVore Dermatology, P.A. for any services furnished to me by that physician. I authorize the release of any medical information necessary toprocess this claim." Signature MEDICARE NON-COVERED SERVICES WAIVER "I understand that there is a$10.00 charge for phoned in prescriptions (CPT and a$40.00 charge for missed appointments or appointments cancelled with less than a2business day notice. I am aware that these charges are not covered by Medicare and that I will be financially responsible for this charge ifand when itis incurred. Signature Witness A3H2A* fln(m.w.16 TO REORDER CALL HHEALTH RECORD SYSTEMS ~"~
3 evore Dermatology, P.^Q Karen A. DeVore M.D. 6^',,,._,. 490 Floyd Road ^_1_ _ SpananburgSC 29307, Fax to ^ to&^s may n0t ^ C Vered ^ ^ insu1'ance Plan- We d0 re^est ac-dit ^^^'Z^r is filed the claim is denied-the price beiow is **.Seborrheic Keratosis, non-irritated ( ,17111 $68 for up to 14, $88 for 15+ Milium ( , $68 for up to 14, $88 for 15+.Neurofibroma ( , $65-$244 Cyst ( , 10061, $99-$186 Keloid ( , 11901, $51-$62 Nevi (mole ( $65-$244.Dermatofibroma ( $ _Skin Tags ( , 11201, $70 for 1-15, then $36 for each additional 10 _Warts ( , 17111, $68 for up to 14, $88 for 15+.Sebaceous hyperplasia ( O, $68 tor up to 14, $88 for 15+ _Angioma ( , $68 for up to 14, $88 for 15+. Corn/Bunion 11055, $27 and up.. Not having areferral or authorization for your health insurance if its required. Signature PrintName ChartNumber" Witness
4 Q UNIVERSAL MEDICATION FORM Name: Phone Number: Birth : Emergency Contact/Phone numbers: Address: form started: IMMUNIZATION RECORD (Record the date/year oflast dose taken, if known TETANUS PNEUMONIA VACCINE Allergic To /Describe Reaction: FLU VACCINE(S HEPATITIS VACCINE OTHER Allergic To/Describe Reaction: LIST ALL MEDICINES YOU ARE CURRENTLY TAKING: Prescription and over-the-counter medications (examples: aspirin, antacids and herbals (examples: ginseng, gingko. Include medications taken as needed (example: nitroglycerin DATE NAME OF MEDICATION / DOSE DIRECTIONS: Use patient friendly directions. (Do not use medical abbreviations. DATE STOPPED Notes: Reason for taking / Doctor Name Refer to back of form for directions, benefits of using the form, and how to get more copies. (09/07 Page of_
5 I. ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES ^IS^urSrfd^.!08 MPriVHCty ^fr^ The n tice d6scribes h W ^ health informati n may be used.htjfn obtain L arevised m copy of 1 the f, Notice Sh0Uld by calling read rt carefully- ' am or aware by requesting that the Notice one at may the office. be changed at any time Imav V Signature ofpatient/guardian Representative* If not the patient, please print your name and relationship to the patient: DISCLOSURE TO OTHER PERSONS REGARDING YOUR HEALTH INFORMATION (Please be aware that you may change this information at any time by requesting to complete anew form. n!sopnrauice h3y discl Se PerSuna' health information about MO" to your referring doctor, family doctor, family close 2 in. t r'^ PerS n that y U identify' 3S l0ng as the 'formation disclosed to those individuals is relevant to n^nn I"6"" '" y Z T " "" Payment ^ y Ur Care' S Practice mav also notifv *«** member o^another person who is responsible for your care of your location and general health condition. Ido not object to my personal health information being disclosed to adoctor, family member, friend or other WnlUOfl in m\/ C_r_ D_ro/\nr> I <-> i+u _:_._ _! I t*.._. individual involved in my care. Persons Iauthorize for disclosure: (List specific namwj II. LAB SERVICES Iobject to my personal health information being disclosed to anyone other than myself. In the event that you have lab work done in this office, you may receive a bill for those services from another vendor A. Pathology specimens will be sent to Celligent Diagnostics B. Blood work will be sent to LabCorp C. Iwill be responsible for any amount insurance does not cover Patientor Guardian Signature Read carefully t>efpre completing- If for insurance purposes pathology specimens or blood work need to be sent elsewhere please indicate where to send them below and notify the nurse at the time of the procedure If at any time this information changes, it isthe patients' responsibility to notify appropriate staff: Pathol 9y Blood work Patient Signature rjate III. COSMETIC INTEREST Please circle any cosmetic interests you would like IV" H W did you hear about us? to discuss with the doctor today. Physician Friend/Family Sclerotherapy (eliminates leg veins Internet Yellow Pages Smoothing Nasolabial Folds (smiie lines Insurance Company Laser Hair Removal Seminar Other: Laser Removal of Vascular Lesions (blood vessels Microdermabrasion (exfoliates skin and cleanses pores Jane Iredale Mineral Makeup Skin Care Products BotOX or Dysport (smooths frown lines Laser Skin Rejuvenation (treats fine lines and sun damaged skin, no down time, encourages collagen growth
6 DeVore Dermatology, P.A. KAREN A. DEVORE, M.D. TrT fq(-u^nca, 490 FLOYD ROAD TEL: ( '7546 SPARTANBURG, SC 29307, FAX;(864 f6' Dear Friends and Patients: Thank you for choosing DeVore Dermatology, P.A. for your dermatological care. Our goal is to provide quality medical care in an efficient matter. Please feel free to give us feedback on what we do well, as well as what we can improve upon. In order to assist us in this goal, please complete the enclosed forms and bring them to your scheduled appointment. Please arrive 15 minutes early and bring with you: a current picture ID insurance card(s medicine list allergy list credit, debit or health savings card Please be familiar with what your insurance company requires. Ifyou need areferral to see a specialist, please call aday or two before your appointment to make sure we have received it from your primaiy care doctor. We collect all applicable copayments/coinsurance and deductibles at time of service. We accept cash, checks, Visa, MasterCard, and Discover. We now request adebit, credit or health savings card on file for all accounts. We will still con tinue to file your insurance; however, we have had an increased problem collecting what insurance does not pay (co-pays, deductibles, percentage after insurance pays. Any amount the insurance states is your responsibility will be applied to the card on file. We take high priority in protecting your credit card information. Please ask us if you have questions. If in the event you are unable to keep your appointment, we kindly ask that you give a2business day notice so that we may pass on your appointment slot to someone else who needs it There is a$?5 charge for last minute cancellations or no shows. Prescription requests will only be considered during normal business hours - not after hours or on weekends or holidays, so please plan ahead. It is in your best interest that we have your medical record with a,st ofyour current medications and allergies when refilling medications. There is a$10.00 charge lorrefilling prescriptions without an appointment. Thank you again for your patience and trust. It is my pleasure to care for you and your family. God Bless You, Karen A. DeVore, M.D. and staff
7 _ How To Find Us From Mary Black Hospital: Once on Skylyn Drive, Mary Black Hospital should be on your left. At the first traffic light after the hospital, make a left. This is Floyd Road. Our office is 1/4 mile on the left. From Gaffney, Gastonia, Charlotte: Merge onto I-85 South. Turn left onto US-221/Chesnee Hwy. Our office is 1 1/2 miles on the right. From Greenville: Merge onto I-85 North Turn right onto US-221/Chesnee Hwy. Ouroffice is 1 1/2 miles on the right. From 1-26 East: " Take 1-26 East to 1-85 North Merge onto 1-85 North via Exit #18B toward Charlotte. Turn right onto US-221/Chesnee Hwy. Our office is 1 1/2 miles on the right. Map: From 1-26 West: Take 1-26 West to 1-85 North Merge onto 1-85 North via Exit #18B toward Charlotte. Turn right onto US-221/Chesnee Hwy. Our office is 1 1/2 miles on the right. UN-Z21 CHURCH CO 52 SKYLYN DRIVE MARY BLACK IfOSWAL * 3 O s SUMMIT KILLS SI'ARTA_NBURO DAY SCHOOL IrttF-SfiYlKIUAN CHUKCH FiAST MAIN STREET 0 TRAFFIC Uliltr DeVore Dermatology, P.A. 490 Floyd Road Spartanburg
We collect all applicable copayments/coinsurance and deductibles at time of service. We accept cash, checks, Visa, MasterCard, and Discover.
DeVore Dermatology, P.A. KAREN A. DEVORE, M.D. TEL: (864) 596-7546 490 FLOYD ROAD FAX: (864) 596-7549 SPARTANBURG, SC 29307 www.devoredermatology.com Dear Friends and Patients: Thank you for choosing DeVore
PATIENT UPDATE FORM. In an effort to have the most up to date information, we ask that this form be completed annually.
PATIENT UPDATE FORM In an effort to have the most up to date information, we ask that this form be completed annually. DATE: CHART: Social Security Number Date of Birth NAME First, Middle, Last MAILING
Cosmetic Interest Questionnaire
Long Ridge Dermatology 1051 Long Ridge Road, Stamford, CT 06903 Tel: 203-329-7960 Fax: 203-329-7920 info@longridgedermatology.com Cosmetic Interest Questionnaire For many people, changes in physical appearance
PATIENT REGISTRATION FORM. Address. Street# Street Name Apt.# City State Zip Code. Employer: Date of Birth: / / Age Month Day Year
PATIENT REGISTRATION FORM Name: Jr. Sr. First Middle Last Prefer to be called: Gender(Sex): M F Married Divorced Single Widowed Race : White Black Asian Indian Other Declined to Provide Ethnicity: Hispanic
PATIENT INFORMATION: NAME: Mr. Mrs. Ms. Miss Last First MI Circle one PHONE: (Home) (Cell) ADDRESS: Street Address City State Zip Code
PATIENT INFORMATION: Date: NAME: Mr. Mrs. Ms. Miss Last First MI Circle one PHONE: (Home) (Cell) E-MAIL ADDRESS: ADDRESS: Street Address City State Zip Code BIRTHDATE: / / AGE: SSN: SEX: M F OCCUPATION:
Cosmetic Medical History
Cosmetic Medical History How did you hear about us? Name Date of Birth / / Today s Date / / Reason for today s visit: Please circle your cosmetic concerns: Sun spots / Age Spots Wrinkles Birthmarks- Brown/Red
Name: LAST FIRST MIDDLE INITIAL. Address: City: State: Zip: SSN: DOB: Age: Home Phone: Work Phone: Cell Phone: Occupation:
Today s Date: Name: LAST FIRST MIDDLE INITIAL City: State: Zip: SSN: DOB: Age: Home Phone: Work Phone: Cell Phone: Occupation: Mailing Address (if different): City: State: Zip: Primary Care Physician:
Insurance Form. Patient Name: Date Last First Middle
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CENTER CITY DERMATOLOGY STEPHEN HESS, M.D., Ph.D. MEDICAL HISTORY
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Patient Registration Form Please present insurance cards and photo ID to the receptionist so copies may be made.
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Amy Wechsler, MD. Dermatology. Welcome To Our Office!
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Patient Information *Please Complete All Sections*
Front Desk Check-In Initials Patient Information *Please Complete All Sections* Account # (Office Use Only) Name (First, MI, Last) Date of Birth / / Age: Sex: M F Mailing Address Apt # City State Zip Home
Cosmetic Medical History
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Laguna Woods Dermatology
Laguna Woods Dermatology Patient Registration Form Visit date: Name: First Middle Last of Birth: Social Security Number: Nickname (optional): Sex: M F Address: Street City State Zip Mr. Mrs. Dr. Home Phone:
Reason for visit today: How did you hear about us?
**Please be sure to fill out EVERY section thoroughly. Indicate N/A for sections that do not apply to you Name: Street Address: Date: City / State: Zip Code: Date of Birth: Gender: Marital Status: Occupation/Employer:
Minor Patient Information
Minor Patient Information MINOR S INFORMATION: (TO BE FILLED OUT BY CUSTODIAL PARENT OR LEGAL GUARDIAN) Last Name: First Name: MI: Goes By (If Different Than Above): DOB: Sex: M F Ethnicity/Race: Preferred
Name: Mr Ms Mrs Dr Last First Initial. Mailing Address: City: State: Zip Code:
Name: Mr Ms Mrs Dr Last First Initial Mailing Address: City: State: Zip Code: Home #: Work #: Cell #: #Preferred: Email: Date of Birth: Age: Sex: F / M Marital Status: M / S / D / W SSN : Employer: Student:
Last Name: First Name: M / F Today s Date: Birthdate: Age: Height: Weight:
NEW PATIENT HISTORY Last Name: First Name: M / F Today s Date: Birthdate: Age: Height: Weight: How did you hear about us? Insurance physician friend other Primary care physician: Name City Phone Referring
Family Physicians of Johnson City 303 Med Tech Parkway, Suite 100 Johnson City, TN 37604
Family Physicians of Johnson City 303 Med Tech Parkway, Suite 100 Johnson City, TN 37604 Patient Registration Form Last Name First Name Middle Initial Sex: M F of Birth Address City State Zip Code Social
PATIENT INFORMATION. (Please complete all sections) NAME OF PARENT(S) OR GUARDIAN(S): PARENT, SPOUSE, OR RESPONSIBLE PARTY If Different from Patient
Date: PATIENT INFORMATION (Please complete all sections) Office Location: PATIENT NAME (Last, First M.I.): DATE OF BIRTH: / / NAME OF PARENT(S) OR GUARDIAN(S): SSN#: SEX: (_) Male (_) Female MARITAL STATUS:
Grekin Skin Institute
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PLEASE. To make your check-in process as smooth and fast as possible: DO NOT DATE THE FORMS BEFORE ARRIVING TO THE OFFICE
PLEASE To make your check-in process as smooth and fast as possible: WRITE LEGIBLY (PRINT) FILL ALL FORMS COMPLETELY DO NOT DATE THE FORMS BEFORE ARRIVING TO THE OFFICE BECAUSE WE WILL SCAN THESE FORMS
Medicine and Surgery of the Foot PATIENT INFORMATION PERSON RESPONSIBLE FOR PAYING THE BILL FAMILY PHYSICIAN INFORMATION HEALTH INSURANCE INFORMATION
PATIENT REGISTRATION Thank you for choosing our office! Please complete all pages. Patient Name: PATIENT INFORMATION Home Address: City: State: Zip: Sex: S S#: Marital Status: S,M,O or minor E-mail: Home
If patient is under 18 y/o, name of Parent/Guardian: Relationship to Patient: Address: (street) (city/state) (zip code)
At both New Tampa Foot & Ankle AND South Tampa Foot & Ankle, we are committed to getting you back on your feet free of pain and injury so that you can get back to your activities and back into life! We
Dermatology Associates of Indy
PATIENT INFO IF REFERRED BY PHYSICIAN GIVE DOCTOR S NAME AND PHONE #: FIRST NAME: LAST NAME: ADDRESS LINE 1: TODAY S DATE: ADDRESS LINE 2: CITY: STATE: ZIP CODE: PRIMARY PHONE #: GENDER: MALE FEMALE CELL
Appt. Date & Time: Patient s Name:
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Patients Name Welcome to Advanced Dermatology (First) (Middle) (Last) Today's Date Date of Birth Gender SS# Patient Employer Name City State Phone ( ) Phone ( ) E-Mail Financial Responsible party (Minors
Advanced Dermatology and Skin Cancer Specialists
PATIENT INFORMATION (Please complete all sections) Date: Office Location: NAME(Last,First M.I.): DATE OF BIRTH: / / NAME OF PARENT(S) OR GARDIAN(S): SSN#: SEX: (_)Male (_)Female MARITAL STATUS: (_)Single
New Patient Information
New Patient Information PATIENT INFORMATION: Last Name: First Name: MI: Preferred Name (If different than above): DOB: Sex: M F Address: Apartment # City: State: Zip Code: Home Phone: Cell: Work: What
Patient Registration Form
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Arizona Center for Aesthetic Plastic Surgery Steven H. Turkeltaub, M.D., P.C. Certified, American Board of Plastic Surgery
Referred By: Patient Last Name First M.I. Sex Marital of Birth Age Status Present Mailing Address - Street City State Zip Social Security # Home Telephone # Cell phone # Business Telephone # E-mail address
YOUR APPOINTMENT IS SCHEDULED FOR:
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Date Referred By: Patient Last Name First M.I. Sex Marital Date of Birth Age Status Present Mailing Address - Street City State Zip Social Security # Home Telephone # Cell phone # Business Telephone #
Registration Form. Patient Name Last First Middle. Patient Address Street/Apt# City State/Zip Code. Sex M F Date of Birth Social Security #
Registration Form Home Phone Work Phone Cell Phone Patient Name Last First Middle Patient Address Street/Apt# City State/Zip Code Sex M F of Birth Social Security # Occupation How did you hear of our practice?
PATIENT INFORMATION & PREFERENCES (Please print or type) YOUR MAJOR HEALTH CONCERNS OR QUESTIONS
Dear Patient: The following questions are designed to collect important information about you and your health. Answering these questions before your office visit will allow more time for a detailed discussion
Employer/Occupation Employer Phone Emergency Contact Relation Phone Referring/Family Physician Phone
PATIENT DATA Please fill out this form so that we will have enough information to effectively bill your insurance. (Only1 form is needed for each patient) Name Date of Birth Sex: F / M Address Phone #1
List all medications you are currently taking (including prescriptions, over-the-counter, & vitamins)
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GREGORY J. STAGNONE, M.D., P.A LBJ Frwy, Ste. 500 Dallas, TX 75240
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Patient Information & Demographics
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Patient Agreement Information
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Alaska Center for Dermatology, P. C Piper Street Suite T4-020 Anchorage, AK telephone fax
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Parent/Guardian Name: Social Security #: Male / Female: Date of Birth: / / Home Phone: Mobile Phone: Work Phone: Street Address: City: State: Zip:
PATIENT INFORMATION Today s : / / Patient Name (Last, Middle, First) Social Security #: Male / Female: of Birth: / / Street Address: Email Address: Home Phone: Mobile Phone: Work Phone: IF THE PATIENT
Who to call for an emergency: Name: Address: Home Phone: ( ) - Work Phone: ( ) - Cell Phone: ( ) - Relationship:
Patient Information: Patient Name: Social Security Number: / / Date of Birth: / / Sex: M / F (Circle one) Married/Single/Divorced/Widow Address: Zip Code: Home Phone: ( ) - E-mail Address: Cell Phone:
o 5801 Allentown Road, Suite 305 Camp Springs, MD 20746
MICHAEL J. FRANK, D.P.M., MARC GOLDBERG, D.P.M., ADAM LOWY, D.P.M. o 10801 Lockwood Dr., Suite 260 Silver Spring, MD 20901 ph. (301) 439-0300 Ix. 681-1488 o 3408 Olandwood Court, Suite 204 Olney, MD 20832
PATIENT INFORMATION DEMOGRAPHICS. First Name Middle Initial Last Name Gender. Mailing address: Apt # City: State: ZIP Code: Home Phone Cell Phone
PATIENT INFORMATION Gary S. Fields, DPM, FACFAS Kenneth M. Danis, DPM, FACFAS DEMOGRAPHICS First Name Middle Initial Last Name Gender SSN Birthdate Age Email M F Mailing address: Apt # City: State: ZIP
Byron J. Van Dyke, M.D. Medical, Surgical, & Cosmetic Dermatology 1158 N. Court Street, Redding, CA Tel (530) Fax (530)
PATIENT: Date of Birth Gender: Male Female Ethnicity: Hispanic Non-Hispanic Single Married Divorced Widowed Race: Caucasian/European-American African/African-American Asian/Asian-American Native American
Name: Last First M.I. Address: Street City State Zip Home Phone: ( ) ( ) ( ) Home Mobile Work ext. Date of Birth: Sex: M F Social Security Number:
PATIENT INFORMATION Name: Last First M.I. Address: Street City State Zip Home Phone: ( ) ( ) ( ) Home Mobile Work ext Date of Birth: Sex: M F Social Security Number: Patient E-mail Address: Marital Status:
Last Name: First Name: M / F Today s Date: Birthdate: Age: Height: Weight:
NEW PATIENT HISTOR Last Name: First Name: M / F Today s Date: Birthdate: Age: Height: Weight: How did you hear about us? Insurance Physician Friend Other Primary care physician: Name City Phone Referring
OUR POLICIES. Prior Authorization for prescriptions is $10.00 for each authorization completed.
OUR POLICIES Effective April 1, 2008, due to continued decreasing insurance reimbursements, we will begin strictly enforcing fees for certain tasks that we perform on behalf of our patients. Phone calls
10485 N. PENNSYLVANIA ST, SUITE 150 BOOTH DERMATOLOGY GROUP 320 N. MERIDIAN ST. SUITE 110 INDIANAPOLIS, IN INDIANAPOLIS, IN WELCOME
WELCOME Appt. & Time: Patient s : Welcome to Booth Dermatology & Cosmetic Center. Thank you for choosing us for your dermatological needs. Please note, if a patient is under 18 years of age, a parent or
Minor Patient Information
Minor Patient Information MINOR S INFORMATION: (TO BE FILLED OUT BY CUSTODIAL PARENT OR LEGAL GUARDIAN) Last Name: First Name: MI: Goes By (If Different Than Above): DOB: Sex: M F Ethnicity/Race: Preferred
Madison Dentistry 424 Madison Avenue 15th Floor New York, NY (212) Patient Information. Health Information
Madison Dentistry 424 Madison Avenue 15th Floor (212)753-7400 Patient Name: Social Security #: Last, First MI (Preferred Name) Gender: Patient Information Birth Date: Family Status: Chart #: FOR OFFICE
MICHAEL J. FRANK, D.P.M., MARC GOLDBERG, D.P.M., ADAM LOWY, D.P.M.
MICHAEL J. FRANK, D.P.M., MARC GOLDBERG, D.P.M., ADAM LOWY, D.P.M. 10801 Lockwood Drive, Suite 260 Silver Spring, Maryland 20901 (301) 439-0300 3408 Olandwood Ct., Suite 204 Olney, Maryland 20832-1367
Welcome and thank you for choosing May River Dermatology, LLC
Welcome and thank you for choosing May River Dermatology, LLC Effective treatment requires good communication. It is critical that the New Patient Packet is completed thoroughly so we can meet your needs.
Georgia Knotek D.D.S. Personalized Dental Care
Georgia Knotek D.D.S. Personalized Dental Care Name: Social Security #: Date of birth: Age: Sex: M / F Phone: Home/Cell Address: City: State: Zip Code: Email: Occupation: Employer: Business Phone: Physician:
West Cary Family Physicians 256 Towne Village Dr Cary, NC
New Patient Registration Form - page 1 PATIENT INFORMATION Patient s first name: Patient s middle name: Patient s last name: Patient date of birth: Patient sex: Marital status: single married Patient s
Medical History Form
Medical History Form Patient Name: Occupation: Why are you here today? Preferred Pharmacy: Pharmacy Phone #: Pharmacy City/Zip: Do you have a primary care physician? Yes No When was the date of your last
HAROLD GOODMAN, D.O SECOND AVENUE SUITE 405B SILVER SPRING, MD Patient Information
Patient Information Name birth date Address (street) apt. # (town, state, zip) Telephone: home cell phone Guardian (if a minor) work e-mail relationship Address (if different) telephone Employer Occupation
Allergies None Penicillin Sulfa Drugs Codeine Aspirin Tape Latex Iodine-Shellfish. Other allergies: Medications
Today s Date: Height Weight Shoe size (CIRCLE) Allergies None Penicillin Sulfa Drugs Codeine Aspirin Tape Latex Iodine-Shellfish Other allergies: Medications SOCIAL HISTORY (CIRCLE) Do you smoke? No Yes
Patient Registration Form
Patient Registration Form PATIENT INFORMATION Please Print Last Name: First: M.I. Mailing Address: City: State: Zip Code: Date of Birth: Gender: M F Married Single Widowed Divorced Separated Partnered
If you are prescribed any medications, where would you like the script sent? Pharmacy Name: Pharmacy Phone:
AMELIA A. PARÉ, M.D. PATIENT REGISTRATION Date of visit: PATIENT INFORMATION (PLEASE PRINT) Name: Date of Birth: Age: Male Female Race Social Security #: Marital Status: Single Married Divorced Widowed
Randall Stettler, D.D.S, Inc 5565 Grossmont Center Dr, Building 1 Suite 129, La Mesa, CA (619)
Randall Stettler, D.D.S, Inc 5565 Grossmont Center Dr, Building 1 Suite 129, La Mesa, CA 91942 (619) 463-4486 PATIENT INFORMATION Last Name First Name Middle Initial *If Patient is a child, Parent/guardian
Please complete entire form
Please complete entire form Patient Name: (Last) (First) (M) Address: City: State: Zip: DOB: Age: Sex: M F Social Security #: (If Using Insurance this is required) Home Phone: Cell Phone: Work Phone: Marital
Patient Information (Please Print)
Page 1 Patient Information (Please Print) Patient s Name: Last First Middle Birthdate: / / SSN: Gender: Male Female Race: Ethnicity: Preferred Language: Marital Status: Single Married Other: Spouse s Name:
6140 W. Atlantic Avenue * Delray Beach, FL Tel: (561) * (888) 357-DERM * Fax: (561)
Today s Date: Reason for Visit: Patient Name: (Last) (First) (Middle) Permanent Address (Local): Street City/State/Zip: Secondary (Out of State) Address: City/State/Zip: Pharmacy Phone: City: Cross Streets:
APPLETON PLASTIC SURGERY CENTER, S. C. (920)
APPLETON PLASTIC SURGERY CENTER, S. C. (920)738-7200 Please print legibly and fill in or correct all fields. Patient Name Parent/Legal Guardian Name Address Last First Middle Last First Middle Street &
Fort Wayne Dental Group
Fort Wayne Dental Group 7202 Engle road * Fort Wayne, Indiana 46804 * (260) 432-3459 PATIENT INFORMATION DATE: NAME: Married Single Male Female LAST FIRST M ADDRESS: STREET APT.# CITY STATE ZIP BIRTHDATE:
SHEILA COOGAN, MD, FACS UT CV Surgery Vascular Specialist
SHEILA COOGAN, MD, FACS UT CV Surgery Vascular Specialist GENERAL INFORMATION Name: Date of Birth: / / Age: Social Security #: / / Sex: M F Marital Status: S M W D Address: City: Zip: Home #: Cell #: Work
Patient Information. Patient Medical Insurance
Patient Name: Referring Physician: Birth Date: Primary Care Physician: Patient ID# +++++ Make corrections on form and alert staff for any pre-filled information that is incorrect +++++ Patient Information
Patient or Parent/Guardian Signature:
Tri State Foot and Ankle Center, LLC Dr. Harold Gruber, DPM Dr. Sandra Hudak, DPM 2018 Naamans Rd. Wilmington, DE 19810 Phone: 302-475-1299 Fax: 302-475-0579 722 Yorklyn Rd. Hockessin, DE 19707 Phone:
Advanced Podiatry. W E A R E V E R Y P L E A S E D T O H A V E Y O U W I T H U S! Please answer the following questions to help us become acquainted.
W E A R E V E R Y P L E A S E D T O H A V E Y O U W I T H U S! Please answer the following questions to help us become acquainted. Date How did you hear about us? (Be Specific Please) First Name Last Name
Please fill this form out completely. Each question is important. If you have any questions please ask. Thank You! Personal Information
Patient Information Please fill this form out completely. Each question is important. If you have any questions please ask. Thank You! Personal Information Today's Date Patient s Name Preferred Name Patient
Who to call for an emergency: Name: Relationship: Home Phone: ( ) - Work Phone: ( ) - Cell Phone: ( ) -
4425 Ponce de Leon Blvd., Suite 115 Email:info@ Dr. Mercedes Gonzalez, Pediatric Dermatologist Patient Information: Patient Name: Social Security Number: / / Date of Birth: / / Sex: M / F (Circle one)
Patient Name: Last First Middle Address: Marital Status: (circle one) Single Married Divorced Widowed Other Gender: Female Male
Patient Information Patient Name: Last First Middle Address: City: State: Zip Code: Home Phone: ( ) - Work Phone: ( ) - Cell Phone: ( ) - Email Address: of Birth: / / Social Security #: - - Marital Status:
DERMATOLOGY CLINIC OF N MS, PLLC (662)
DERMATOLOGY CLINIC OF N MS, PLLC (662) 349-0200 Patient Information as of (enter today s date) (Please Print Legibly & Fill In or Correct All Fields) Patient s Name MRN: Last First Middle Initial Mailing
New Patient. Patient Name: Age: Sex: Weight: Height: Date:
New Patient Patient Name: Age: Sex: Weight: Height: Date: Are you currently taking any medication (including prescription, over-the-counter, herbs, vitamins/supplements)? If yes, please list name, dosage,
Stonebridge Adult Medicine, P.A. Registration Form (Please Print)
Stonebridge Adult Medicine, P.A. Registration Form (Please Print) PATIENT INFORMATION Last Name: First Name: Is this your legal name? Yes No If not what is your legal name: Date of Birth: Sex: male female
Registration Form. City: State: Zip: Birthdate: Marital Status: M S W D. Patient Employer: Occupation: Employer Address: Emp.
Registration Form Patient Information Name: Address: SS#: Phone: City: State: Zip: Sex: F M Birthdate: Marital Status: M S W D Patient Employer: Occupation: Employer Address: Emp. Phone: Whom may we thank
PALMETTO PULMONARY MEDICINE, P.A.
Peter N Manos, MD FCCP Denise Mercier, PA-C Board Certified: Internal Medicine Pulmonary Disease Critical Care Medicine Sleep Medicine 989 Ribaut Road, Suite 340 Beaufort, SC 29902 (843)-521-8484 Fax (843)
Buckland Ear, Nose & Throat, LLC. Medical History
Buckland Ear, Nose & Throat, LLC Medical History Patient Name: Today s Date: Primary Care Provider: Referred by: Pharmacy You Use: Date of Birth: Age: Name City 1. Reason for visit: 2. Past Medical History:
MEMORIAL AND KATY SURGICAL SPECIALISTS. Patient Information
Patient Information Patient Name Last First Middle Address City State Zip Birthdate Age Sex M F Social Security# Race (Please circle) American Indian Asian Black Native Hawaiian Pacific Islander White