Sex: Male Date of Birth: / / Age: Social Security #: - - Female Address: (Street Address) (Town/City) (State) (Zip)

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Stephanie Pearson
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1 Mohs Surgery, Cosmetic Skin Surgery, Laser Skin Surgery Amir Bajoghli, MD; Janice Rasmussen, NP-C; Suzanne Adler, PA-C 8130 Boone Blvd, Suite 340, Tysons Corner, Virginia Opitz Blvd, Suite 100, Woodbridge, Virginia Hospital Center Blvd., #105 Stafford, VA PATIENT INFORMATION Date: (month) /(day) /(year) Preferred Language: English Spanish Other Name: (Last) (First) (MI) Do you have a preferred name or nick name?: Sex: Male Date of Birth: / / Age: Social Security #: - - Female Address: (Street Address) (Town/City) (State) (Zip) Home Telephone No: ( ) Cell Phone No: ( ) What is the best way for us to reach you? Home Cell Other Phone ( ) May we leave a message about your test results? YES/NO with Spouse, Household member, Other Marital Status: Single Other Married *Can we send you any information via your ? YES/NO Race: Ethnicity: Emergency Contact Name: Relation to patient Phone: ( ) Is patient employed? YES/NO (Please Circle) If employed, please fill out the following: Name of Employer: Phone: ( ) Address: ADDITIONAL INFORMATION Name of PRIMARY CARE PHYSICIAN: Phone: ( ) Address: Please list any other physicians who you see: Name of PHARMACY: Address: (Street Address) (Town/City) (Zip) Phone: ( ) Fax: ( ) How did you hear about us? PLEASE Circle ALL that applies: a. Insurance Company Website or Directory b. Friend/ Relative/Colleague c. Doctor s Name: d. Yellow Pages (Verizon / Yellow Book/ Local-Community Book) e. Google Search f. Internet/Website name: g. Other Name of parents or guardian (if patient is child): Father: Social Security #: - - Mother: Social Security #: - - PLEASE TURN OVER.

2 Mohs Surgery, Cosmetic Skin Surgery, Laser Skin Surgery Amir Bajoghli, MD; Janice Rasmussen, NP-C; Suzanne Adler, PA-C 8130 Boone Blvd, Suite 340, Tysons Corner, Virginia Opitz Blvd, Suite 100, Woodbridge, Virginia Hospital Center Blvd., #105 Stafford, VA PRIMARY Insurance Information Name of Policy Holder Date of Birth of Policy Holder: / / Social Security # of Policy Holder: - - Name of Primary Insurance: ID NO: Primary Insurance Co. Phone #: ( ) Group #: Policy Holder s Address: (Street/P.O. Box) (Town/City) (State) (Zip Code) Employer Insurance Plan? Yes No Relationship of Patient and Policyholder: Self Husband Wife Child Parent SECONDARY Insurance Information Name of Policy Holder: Date of Birth of Policy Holder: / / Social Security No. of Policy Holder: - - Name of Secondary Insurance: ID #: Secondary Insurance Phone #: ( ) Group #: Policy Holder s Address: (Street/P.O. Box) (Town/City) (State) (Zip Code) Employer Insurance Plan? Yes No Relationship of Patient and Policyholder: Self Husband Wife Child Parent Insured s Employment Information: Name of Employer: Phone: ASSIGNMENT & RELEASE I hereby authorize Skin & Laser Surgery Center, PC to apply for benefits on my behalf for covered services rendered. I, further, authorize the release of any necessary information, including medical information for this or any related claim, to my insurance carrier, (or in the case of Medicare Part B benefits to the Social Security Administration and Health Care Financing Administration). A copy of the authorization may be used in place of the original. Either my insurance carrier or I may revoke this authorization at any time in writing. I certify that information I have reported with regard to my insurance coverage is correct. I authorize Dr. Bajoghli, Associates and staff to treat me. I hereby authorize payment of all medical insurance benefits which are payable to me under the terms of my insurance policy to be paid directly to Skin & Laser Surgery Center, PC for services rendered. I further authorize the release of any information needed for processing my insurance claims. A copy of this authorization may be used in place of the original. In the event my health plan determines a service to be non-covered, I will be responsible for the complete charge. Skin & Laser Surgery Center, PC will bill me directly and payment is due upon receipt of the statement. Skin & Laser Surgery Center, PC will also bill your health plan for all services we provide in the hospital. For all services rendered to minor patients, the adult accompanying the patient is responsible for payment. I understand and agree that I am financially responsible for charges not covered by my insurance company. APPOINTMENT POLICY There will be a $50.00 charge for a NO SHOW office visit or an $85.00 charge for NO SHOW SURGERY appointment. We strictly enforce this policy, so please take time to carefully select your appointment time. A broken appointment is a cancellation without a 24-hour notice, lateness that results in the inability to properly complete the treatment planned, or not being present for the scheduled appointment. This charge is the patient s responsibility and is not reimbursed by the insurance company. PAYMENT POLICY Self pay accounts and co-pays are due at the time of service; there is no exception to this policy. If it becomes necessary to turn your account over to a collection agency/attorney, there will be a charge of 35% additional fee applied to your total balance to cover attorney s fees and other collection costs. If your check bounces (due to insufficient funds or any other reason) you will be charged $ I authorize Skin & Laser Surgery Center, PC to deduct my bounced check amount AND the associated fees (minimum of $50) from my bank account directly through Automated Clearing House (ACH. A 1.5% monthly finance charge will be charged to all due past due amounts. I authorize Skin & Laser Surgery Center, PC to collect the fees associated with patient responsibility of medical and surgical services rendered. This may include co insurance amount, deductibles, co-pays, or any other balances due. INSURANCE COVERAGE It is not Skin & Laser Surgery Center s responsibility to confirm whether the patient has in-network or out of network benefits. Ultimately, it is the patient s responsibility to confirm what their coverage benefits are with their insurance company. X SIGNATURE OF PATIENT, PARENT OR GUARDIAN DATE

3 Dermatology, Mohs, Laser and Cosmetic Skin Surgery NAME: Date: (month) /(day) /(year) What is the reason for your visit today? When did the problem begin? What body locations are involved? Is it associated with: Bleeding Itching Stinging Other What have you used to the area so far and has it worked? Have you been evaluated by another physician for this problem? Do you have any moles or growths that are changing in color, size, shape? History and Intake Form Past Medical History: (please circle all that apply) Anxiety Arthritis Asthma Atrial fibrillation COPD (Emphysema) Coronary Artery Disease Depression Diabetes Renal Disease GERD (Acid reflux) Glaucoma/Cataracts Heart murmur Hearing Loss Hepatitis A/B/C Hypertension HIV High Cholesterol Hyperthyroidism Hypothyroidism Liver disease Pacemaker/Defibrillator Psychiatric condition Peptic ulcer Radiation Treatment Seizures/Epilepsy Tuberculosis Joint Replacement Stroke Other Do you have a history of cancer? Yes / No If so, what type? Have you had any surgical procedures? Yes / No If so, what type and the year that you had them? Skin Disease History: (please circle all that apply) Acne Actinic Keratosis Basal Cell Skin Cancer Blistering Sunburns Dry Skin Poison Ivy Eczema Flaking or Itchy Scalp Keloids Melanoma Precancerous Moles Psoriasis Squamous Cell Skin Cancer Cold sores/fever blisters Other Do you wear Sunscreen? Yes / No If yes, what SPF? Do you tan in a tanning salon? Yes / No Do you have a family history of skin cancer? Yes / No If yes, what kind? Basal cell, Squamous cell, Melanoma, Other Which relative(s)? Do you have a family history of Vitiligo, Lupus, Psoriasis, or Eczema? Yes / No Review of Systems: (please circle all that apply) Problems with healing Problems with scarring Fever or chills Night sweats Unintentional weight loss Asthma Hay fever Problems with bleeding Blurry vision Sore throat Thyroid problems Chest pain (right now) Abdominal pain Bloody urine Bloody stool Joint aches Muscle weakness Headaches Seizures Cough Wheezing Anxiety Depression Medications: Please enter all current medications including over the counter medications(this includes vitamins, birth control pills, Ginseng, Gingko Biloba) Do you take antibiotics prior to procedures? Yes / No Allergies: (Please enter all allergies) Social History: (Please circle one) Are you pregnant/ lactating? Yes / No Do you smoke cigarettes? Yes / No If so, how many packs per day? Do you drink alcohol? Yes / No If so, how frequently? Do you have any pets? Cats, Dogs, Birds, None, Other What is your occupation?

4 Skin & Laser Surgery Center, PC HIPAA RELEASE Authorization for Use and Disclosure Patient Name: Last First MI Maiden or Other Name Date of Birth: - - SS #: Phone: Address: City: ST: Zip: Date of Service: I authorize Skin & Laser Surgery Center, PC to use and disclose my protected health information for its own purposes of treatment, payment, and health care operations. I authorize Skin & Laser Surgery Center, PC to disclose the following records related to the date above: I authorize to disclose the following records related to the date above: Records: All records Medical Records To include: Diagnostic Records (lab, x-ray, etc.) Treatment Records Billing/Claims Records HIV/STD Drug and alcohol related Please release these records to: COVERED ENTITY or INDIVIDUAL LISTED BELOW NAME: ADDRESS: CITY: STATE: ZIP: PHONE: FAX: For purposes of treatment, payment, health care operations, or other If the person or entity receiving this information is not a health care provider or health plan covered by federal privacy regulations, the information described above may be disclosed to other individuals or institutions, per your request, and no longer protected by these regulations. You may revoke this authorization in writing at any time by sending written notification to: Kristina Joseph, Office Manager Skin & Laser Surgery Center, PC 2200 Opitz Blvd, Ste. 100 Woodbridge, VA Please note: Revocations do not apply to information that has already been disclosed or used before revocation has been received. You may decline to sign this authorization. Declining to sign will not affect your ability to obtain treatment or payment or your eligibility for benefits unless this authorization is being performed solely to create information to be sent to another entity.you have the right to receive a copy of this authorization. This authorization expires one year from date of signing or on. SIGNATURE OF PATIENT DATE PARENT/LEGAL GUARDIAN/AUTHORIZED PERSON : DATE RELATIONSHIP TO PATIENT (IF APPLICABLE):

5 CENTER FOR SKIN CANCER SURGERY AMIR A. BAJOGHLI, M.D. Diplomate, American Board of Dermatology and Internal Medicine Fellow, Procedural Dermatology Section, Association of Professors in Dermatology MOHS Micrographic Surgery Laser Cutaneous Surgery Please read and sign below: I,., am aware that if I do not make payments to any outstanding balance I may have, within 30 days of receiving a statement, my account will be sent over to Collections. In addition to having to pay my balance, there will automatically be an additional 35% for collection fees. Print name Patient Signature Date OFFICE USE ONLY: Date of Service: Doctor seen: Insurance: 2200 Opitz Blvd. #100 Woodbridge, VA (703) Fax (703) Hospital Center Blvd. #105 Stafford, VA (800) (703) Boone Blvd. #340 Vienna VA (703) Mohssurgery@yahoo.com

Natural Image Skin Center Registration Form

Natural Image Skin Center Registration Form New Patient Name Change Address Change Insurance Change Please present ALL Insurance cards to the receptionist. If patient is a minor, and you are not the legal