PATIENT INFORMATION. Patient s last name: First: Middle: Marital status:
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1 Today s Date: PATIENT INFORMATION Patient s last name: First: Middle: Marital status: Is this your legal name? If not, what is your legal name? Former name: Birth date: Age: Sex: Yes No M F Address: [Address/ P.O Box, City, ST ZIP Code] Social Security no.: Home phone no.: Cell phone no.: Occupation: Employer: Employer phone no.: Chose clinic because/referred to clinic by (Please choose one option): [Doctor s name] [Choose an item] Other family members seen here: INSURANCE INFORMATION (Please give your insurance card to the receptionist.) Person responsible for bill: Birth date: Address (if different): Home phone no.: [Responsible party] [Birthday] [Address] [Phone] Is this person a patient here? Yes No Is this patient covered by insurance? Yes No Occupation: Employer: Employer address: Employer phone no.: [Occupation] [Employer] [Address] [Phone] Please indicate primary insurance: [Choose an item] Other: [Other insurance] Name of Policy Holder: Subscriber s S.S. no.: Birth date: Group no.: Policy no.: Co-payment: Patient s relationship to subscriber: [Choose an item] Other: [Relationship to subscriber] Name of secondary insurance (if applicable): Name of Policy Holder: Group no.: Policy no.: Patient s relationship to subscriber: [Choose an item] Other: [Relationship to subscriber] IN CASE OF EMERGENCY Name of local friend or relative (not living at same address): Relationship to patient: Home phone no.: Work phone no.: The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize [Name of Practice] or insurance company to release any information required to process my claims. Patient/Guardian signature Date
2 Dermatology And Skin Surgery Center Dr. Juan A. Mujica Dr. Maria R. Pico Dr. Neville G. Pereyo Dr. David Pharis Matthew Brunner, PA-C Christopher Golden, PA-C Vanessa Winokur, PA-C Monica Sohani, PA-C 210 Village Center Parkway Stockbridge GA, PH: 770) PATIENT CONSENT FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMAITON (PHI) I have the right to review the Notice of Privacy prior to signing this consent. 1. With my consent, DERMATOLOGY AND SKIN SURGERY CENTER may use the following methods to communicate with me: - Call to my home or other designated location and leave a message on voic or in person - Mail to my home or other designated location - to my home other designated location 2. I also understand and consent that my personal health information may be disclosed to other appropriate entities, such as (but not limited to) my insurance company(ies), other physicians or health care providers and others as indicated in the Notice of Privacy Practices. 3. I have the right to request that DERMATOLOGY AND SKIN SURGERY CNETER restricts how it uses or discloses my personal healthy information. I request the following restriction(s): The practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement. The above restrictions ARE, ARE NOT agreed to by DERMATOLOGY AND SKIN SURGERY CENTER. Signed: Position/Title: Date: 4. If I do not sign this consent, DERMATOLOGY AND SKIN SURGERY CENTER may decline to provide treatment to me. I may revoke my consent in writing, except to the extent that the practice has already made disclosures in reliance upon my prior consent. By signing this form I am consenting to DERMATOLOGY AND SKIN SURGERY CENTER S use and disclose of my personal health information (PHI) to carry out treatment, payment, and operation (TPO). I also aurthorize assignment of insurance benefits to DERMATOLOGY AND SKIN SURGERY CENTER. Signature of Patient or Legal Guardian Signature of Patient or Legal Guardian Patient s or Guardian s Printed Name Date
3 DERMATOLOGY AND SKIN SURGERY CENTER, LLP reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a writing request to Ms. Vicki Heath, Privacy Office at 210 Village Center Parkway, Stockbridge GA, PLEASE COMPLETE THE FOLLOWING MEDICAL HISTORY FORM Name Today s Date Age Sex Referring Doctor Reason for today s visit: Skin areas involved: How long has the problem been present? Has a biopsy been done? No Yes Was there any previous treatment? No Yes What? LIST ALL MEDICATIONS (include vitamins, herbs, supplements) ALLERGIES: Pharmacy of choice PAST MEDICAL HISTORY (circle all that apply): Anxiety Arthritis Artificial joints Asthma Atrial fibrillation BPH Bone marrow transplant Breast cancer colon cancer COPO Coronary artery disease Depression Diabetes End state renal disease GERD Hearing loss Hepatitis Hypertension HIV/AIDS Hypercholesterolemia Hyperthyroidism Leukemia Lung cancer Lymphoma Pacemaker Prostate cancer Radiation treatment Seizures Stroke Valve Replacement Other: None:
4 PAST SURGICAL HISTORY (circle all that apply): Appendix removed Bladder removed Mastectomy (right, left, both) Lumpectomy (right, left, both) Breast biopsy (right, left, both) Breast reduction Breast implants Colectomy (colon cancer resection) Colectomy (diverticulitis) Colectomy (IBD) Gallbladder removed Coronary artery bypass PTCA Valve replacement Heart transplant Joint replacement (which?) Kidney biopsy Kidney removed (right, left) Kidney stone removal Kidney transplant Ovaries removed: endometriosis Ovaries removed: cysts Ovaries removed (ovarian cancer) Prostate removed (prostate cancer) Prostate biopsy TURP Skin biopsy Skin cancer surgery spleen removed Testicles removed (right, left, both) Hysterectomy (fibroids) Hysterectomy (uterine cancer) Other: None: SKIN DESEASE HISTORY (circle all that apply): Acne Actinic keratosis Asthma Blistering sunburns Dry skin Eczema Flaky/Itchy scalp Hay fever/ allergies Poison Ivy Precancerous moles Psoriasis Skin cancer (where & when?) Do you wear sunscreen? No Yes SPF Do you tan at a tanning solon? No Yes Do you have a family history of melanoma? No Yes Who? SOCIAL HISTORY (circle all that apply) Currently smokes daily Currently smokes occasionally Has smoked in the past Has never smoked Drug use: Sexual partners: one or multiple
5 REVIEW OF SYSTEMS (circle any that applies) Abdominal pain Allergy to adhesives Allergy to lidocaine Allergy to topical antibiotics Artificial heart valve Artificial joint w/in last 2 years Bloody stools Bloody urine Blurred vision Changing mole Chest pain Cough/wheezing Defibrillator Fever/chills Headaches Immunosuppression Joint aches Muscle weakness Neck stiffness Need premedication prior to procedures Night sweats Pacemaker Pregnancy/working on it Problems with bleeding Problems with healing Problems with scarring (keloid or hypertrophy) Rapid heartbeat w/ epinephrine Rash Shortness of breath Sore throat Stomach upset w/ antibiotics Taking blood thinners Unintentional weight loss Yeast infection w/ antibiotics
6 NON-COVERED SERVICES I understand that the following procedures / services are usually considered as non-covered services. If I request medical or surgical treatment for these diagnosis, I will be responsible for the fees. Acrochordons (skin tags) Alopecia (hair loss) Benign (moles) Hair removal (waxing, laser, electrolysis) Lentigo (liver spots, age spots) Keloid (injections/ surgery) Dermabrasion Scar revision/ acne scarring Seborrheic keratosis Facials Spider veins (leg & facial) Tattoo removal Dilated blood vessels Liposuction Laser surgery/ consult Injections (cortisone) Chemical peels Milia (cysts) Ear piercing Make pattern baldness Split earlobe repair Sebaceous hyperplasia Wrinkles PREASE READ OUR FINANCIAL POLICY - All cosmetic surgeries/ procedures are to be paid for in full, prior to procedure being done. - All co-payments will be collected upon completion of the Patient Information Sheet or at signin prior to seeing the physician. - If we are not a provider for your insurance, or if you have not met your deductible, or are ineligible for benefits, FULL PAYMENT WILL BE COLLECTED TODAY. - Deposits for procedures are non-refundable - All billed balances must be paid within 30 days of 1 st billed date, after which they are subject to collection efforts - All returned checks are subject to a $30.00 returned check fee. - TISSUE SPECIMEN WILL BE SENT TO A BOARD CERTIFIED DERMATOPATHOLOGIST, WHO WILL BILL A SEPARATE FEE. PATIENT SIGNATURE (OR GUARDIAN) DATE
7 Authorization for Release of Information Name of Patient Date DERMATOLOGY AND SKIN SURGERY CENTER is authorized to release protected health information about the above named patient to entities named below. The purpose is to inform the patient or other sin keeping with the patient s instructions. Entity To Receive Information Check each person/entity that you approve to receive informaiton Voice Mail- Spouse (provide name) Parent (provide name) Other (provide name) Description of information to be released Check each that can be given to person/entity on the left in the same section. Results of lab test/ x-rays Other Financial Medical as follows Financial Medical as follows Financial Medical as follows Patient Information: I understand that I have the right to revoke this authorization at any time and that I have the right to inspect or copy protected health information to be disclosed as describes in this document. I understand that a revocation is not effective in cases where the information has already been disclosed but will be effective going forward. I understand that information used or disclosed as a result of this authorization maybe subject to re-disclosure by the recipient and may no longer be protected by federal or state law. I understand that I have the right to refuse to sign this authorization and that my treatment will not be conditioned on signing. THIS AUTHORIZATION SHALL BE IN EFFECT UNTIL REVOKED BY PATIENT. Signature of Patient or Personal Representative Date
8 (Description of Personal Representative s Authority- attach necessary documentation)
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103 W. South St. Woodstock, VA. 22664 Winchester, VA. 22602 (540) 409-5254 Office * (540) 409-5253 Fax Financial Policy We make every effort to provide prompt medical care to each of our patients. Effective
INSURANCE INFORMATION (Please present insurance cards at the time of check in)
421 N. RODEO DR., SUITE T-7, BEVERLY HILLS, CA 90210 T: (310)274-5372 F: (310)274-5380 Date: / / PATIENT REGISTRATION FORM Name: Jr. Sr. Last First Middle Prefer to be called: Title: Mr. Mrs. Ms. Miss
How Can We Assist You Today?
www.oaklandhillsdermatology.com How Can We Assist You Today? Cosmetics Dermatology Products Acne Program Acne Acne Products Acne Scar Treatment Actinic Keratosis History Age Defense Products Ageless Glow
Street Address: Apt. # City State Zip. Employer Name and Address. City State Zip. Name of Spouse or Guardian. Emergency Contact Name and Phone
Patient Name Social Security Number: Date of Birth: Age: Street Address: Apt. # City State Zip Home Phone: ( ) -- Mobile Phone: ( ) -- Employer Name and Address City State Zip Business Phone ( ) -- Occupation
Thank you for choosing our practice. Please download all of the attached forms, complete and bring them with you to your appointment.
re' ILLINOIS DERMATOLOGY ID INSTITUTE Dear New Patient, Thank you for choosing our practice. Please download all of the attached forms, complete and bring them with you to your appointment. Please bring
Welcome to Advanced Dermatology
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
Patient (Optional).
ALAN R. MALOUF, MD, PA 17000 Science Drive, Suite 108 PATIENT REGISTRATION PLEASE PRINT First Name Ml Last Name Address City. State Zip Code Home# Work# Cell # Male/Female Date of Birth Marital Status
New Patient Information
New Patient Information LAST FIRST NAME NAME M.I. DATE OF SOC. MARITAL BIRTH SEC. SEX STATUS PRIMARY ADDRESS PHONE CELL CITY STATE ZIP PHONE WORK EMPLOYER PHONE REFERRING/ LAST YOUR PRIMARY PHYSICIAN SEEN
Welcome Carlos Paz, MD, PhD Melissa Manriques, FNP Michelle Flores, FNP
Welcome Dear Patient, We are delighted to welcome you to Fresno and Visalia Dermatology Specialists, the offices of Dr. Carlos Paz. This letter contains answers to some of the most commonly asked questions
Sex: Male Date of Birth: / / Age: Social Security #: - - Female Address: (Street Address) (Town/City) (State) (Zip)
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 221822200 Opitz Blvd, Suite 100,
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
Street City State Zip. Home Phone Work Phone. Cell Phone . Occupation Employer. Referring Physician Primary Physician
PATIENT INFORMATION (please print) Full Name: Preferred Name: (first) (middle) (last) Social Security Number Birthdate: Age Male Female Street City State Zip Home Phone Work Phone Cell Phone E-mail Occupation
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:
Welcome to Florida Eye Institute!
Welcome to Florida Eye Institute! We look forward to greeting you as a new patient. Having served the Vero Beach community for over 30 years, it is our steadfast goal to help you achieve the best vision
Patient Registration Form Please complete all the information below in print, please do not leave any questions blank. Thank You!
Patient Registration Form Please complete all the information below in print, please do not leave any questions blank. Thank You! PATIENT INFORMATION: Last Name: First Name: Middle: Date of Birth: Home
Patient Information Form
AND COSMETIC SURGERY PATIENT Patient Information Form Please complete both sides of this form in ink and sign where indicated. INFORMATION Patient Name (last, fi rst, middle initial) Date / / Date of Birth:
Address: City/State: Zip: Employer: Occupation: Address: Phone: Emergency Contact: Phone: ( ) - PRIMARY INSURANCE: Address:
Patient Name: Preferred Name: DOB: Age: SSN: E-mail address (Optional): Address: City/State: Zip: Home Phone:( ) - Cell Phone: ( ) - Sex: M / F Married Single Divorced Widowed Employer: Occupation: Address:
Patient Registration Form
I Patient Registration Form Please Print Clearly and Fill in All the Blanks PATIENT INFORMATION First Name: Middle Initial: Last Name: DOB: Age Address: Apt #: City: State: Zip: SSN: Driver License Number:
Responsible Party (if different from patient) Name: Relationship to patient: Phone: Address:
New Patient Demographics Form Appt time: Arrival time: Name: Date of Birth: (Please Print First, M, Last) Sex: Female Male Marital Status: SSN: Home Address: Email: Preferred Phone Number: Alternate Phone
ADVANTAGE DERMATOLOGY, P.A.
ADVANTAGE DERMATOLOGY, P.A. PATIENT DEMOGRPAHIC INFORMATION (Please Print) LAST NAME FIRST NAME MIDDLE INITIAL Street Address City State Zipcode Home Phone Cell Phone Work Phone (If applicable) Date of
FINANCIAL POLICY AND AGREEMENT
FINANCIAL POLICY AND AGREEMENT Our office is committed to providing excellent, affordable medical care. You have the right and responsibility of knowing the cost of your medical treatment. Should you be
Acknowledgement of Receipt of Notice of Privacy Practices. Benefits to Physician. Release of Information
PATIENT REGISTRATION : Patient Name: of Birth: Marital Status: Last, First Address: City: State: Zip: Street/Apt #/PO Box Home #: Cell #: Work #: Email: Sex: F M SSN #: Referred by: *Physician Patient
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