Thank you for choosing our practice. Please download all of the attached forms, complete and bring them with you to your appointment.
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- Percival Dorsey
- 6 years ago
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1 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 your Photo ID and Insurance Card(s) to your initial visit. Please confirm with your insurance company that your IDI provider is in your insurance network and note all of our IDI NPI (National Provider Identifier) numbers are posted on this website for your convenience. Of course we welcome all patients and wish to remind you to bring in a referral to your visit should your insurance plan require one. 3 I We look forward to meeting you soon! Your IDI Team Dr. David Loiter Dr. na Craig Dr. Jennifer Croix Dr. Sara Dickie Erin Melley, PA-C Amanda Schallman, PA-C
2 Patient Name: DOB: / / MRN (office use only): Provider (Please circle): Dr. Lorber Dr. Craig Dr. Croix Erin Melley PA-C Amanda Schallman PA-C Today's Date: / / Reason for today's visit: Please check all of the following boxes that apply: Past Medical History p Anxiety 0 Arthritis Asthma Atrial Fibrillation (irregular heartbeat) BPH (enlarged prostate) El Bone Marrow Transplant Breast Cancer Colon Cancer COPD 0 Coronary Artery Disease Depression Diabetes End Stage Renal Disease GERD (Gastric Reflux) Hearing Loss Hepatitis Hypertension (high blood pressure) HIV/AIDS Hypercholesterolemia (high cholesterol) Hyperthyroidism Hypothyroidism Leukemia Lung Cancer Lymphoma Prostate Cancer Radiation Treatment 0 Seizures Stroke Other: 0 NO PAST MEDICAL PROBLEMS Past Surgeries Appendix (Appendectomy) Bladder (Cystectomy) Breast: Mastectomy (Right Breast) Breast: Mastectomy (Left Breast) Breast: Mastectomy (Both Breasts) Breast: Lumpectomy (Right Breast) Breast: Lumpectomy (Left Breast) Breast: Lumpectomy (Both Breasts) Breast: Breast Biopsy Breast: Breast Reduction Breast: Breast Implants Colon (Colectomy): Colon Cancer Resection Colon (Colectomy): Diverticulitis Colon (Colectomy): Inflammatory Bowel Dz Gallbladder (Cholecystectomy) Heart: Coronary Artery Bypass Surgery Heart: PTCA (angioplasty) Heart: Mechanical Valve Replacement Heart: Biological Valve Replacement Heart: Heart Transplant Past Surgeries Continued El Joint Replacement: Knee (Right) 0 Joint Replacement: Knee (Left) 0 Joint Replacement: Knee (Both) 0 Joint Replacement: Hip (Right) Joint Replacement: Hip (Left) 0 Joint Replacement: Hip (Both) Kidney: Kidney Biopsy Kidney: Nephrectomy (Kidney Removal) Kidney: Kidney Stone Removal Kidney: Kidney Transplant Ovaries (Oophorectomy): Endometriosis 0 Ovaries (Oophorectomy): Ovarian Cyst 0 Ovaries (Oophorectomy): Ovarian Cancer Prostate (Prostatectomy): Prostate Cancer Prostate (Prostatectomy): Prostate Biopsy Prostate (Prostatectomy):TURP Skin: Skin Biopsy Skin: Basal Cell Carcinoma Surgery 0 Skin: Squamous Cell Carcinoma Surgery Skin: Melanoma Surgery Spleen (Splenectomy): Spleen Removal Testicles (Orchidectomy): Testicle Removal Uterus (Hysterectomy): Fibroids Uterus (Hysterectomy): Uterine Caner Other: 0 NO PAST SURGICAL PROCEDURES Skin Disease History Acne Actinic Keratoses (precancers) 0 Asthma Basal Cell Skin Cancer Blistering Sunburns Dry Skin Eczema Flaking or Itchy Scalp Hay Fever/Allergies Melanoma Poison Ivy Precancerous/Dysplastic Moles Psoriasis Squamous Cell Skin Cancer NO PAST SKIN PROBLEMS Skin History Do you wear sunscreen? 0 Yes. What SPF do you apply? Do you tan in a tanning salon? 0 Yes Family History of Melanoma Do you have a family history of Melanoma? (t basal cell or Squamous Cell Carcinoma) 0 Yes. Which relative(s)? 0 Family History of Other Cancer Yes Relative Relative Type: Type: Do we have your permission to import list of medications from your pharmacy? 0 Yes 0 Have you had a Flu shot within the last 12 months? 0 Yes Medications: (Please list all medications, Including over the counter, supplements, etc.) 0 NO CURRENT MEDICATIONS Medication Allergies: (Please list all allergies) 0 NO KNOWN MEDICATION/DRUG ALLERGIES Over I >
3 Name MRN Pneumonia Vaccine Alerts Important info to know about you: Did you receive the Pneumovax vaccine? Defibrillator Name: Primary Care Physician 0 Yes Pacemaker Referred you to our practice? YES or NO 0 Artificial Joint Placed in Last 2 Years Phone: Artificial Heart Valve Drinking Alcohol History 0 Antibiotic Prophylaxis City: Hospital Affiliation: 0 alcohol o History of Scarring (Keloid) Preferred Pharmacy Information CI Less than 1 drink per day 0 History of Passing Out (Vasovagal) Pharmacy Name drinks per day o Organ Transplant Recipient City 0 3 or more drinks per day o lmmunosuppressed (Low Immunity) Street 0 Allergy to Adhesive Smoking History o Pregnant or Planning a Pregnancy Marital status: 0 Current every day smoker o Breast Feeding OM OS OD OW o Current some day smoker (cigarette) o Stomach Upset with Antibiotics 0 Current some day smoker (other tobacco) 0 Yeast Infection with Antibiotics Preferred Language: o Former smoker 0 Allergy to topical antibiotics 0 English- 0 Spanish 0 Other Quit smoking date: / / 0 Anti-coagulated (on blood thinners) Total years smoking: 0 Allergic to Lidocaine Race: o Never smoker o Rapid heartbeat with Epinephrine 0 White 0 HIV/AIDS 0 American Indian or Alaska Native Review of Systems Have you recently o Hepatitis C Asian experienced any of the following: o History of MRSA 0 Black or African American O Changing, bleeding or itching mole/lesion o Problem with UV therapy 0 Native Hawaiian or other Pacific Islander 0 Rash o Heart Stent 0 Other Race: 0 Itching o Problem with steroids o Burning Skin o History of stroke Ethnic Group: o Fever/Chills ii History of heart attack 0 Hispanic or Latino o Unintentional Weight Loss o History of atrial fibrillation 0 t Hispanic or Latino o Night Sweats o Arrhythmia 0 Unknown o Muscle Weakness 0 Latex allergy 0 Joint Aches 0 West Africa: Travel or Contact Occupation/Workplace: o Neck Stiffness o NONE o Headaches o Seizures Female Patients Only How did you hear about us? 0 Blurry Vision Are you pregnant? 0 Physician: 0 Chest Pain o Yes Due Date 0 Family: o Shortness of Breath o 0 Friend: 0 Cough Are you breastfeeding? 0 Insurance Referral 0 Sore Throat o Yes 0 Internet search o Abdominal Pain/Nausea/Vomiting o Other: o Bloody Stool o Depression Preferred Method of Contact o Hay Fever o Phone: Advanced Care Plan: Medicare has requested us to ask patients 65 and older, the following question: 0 Problems Healing (please circle: mobile, home, work) Do you have an Advance Care Plan or Surrogate 0 Burning with urination 0 Letter Decision Maker? o Heat or cold intolerance o Fax: O Frequent nose bleeds (EX: Living Will, Health Care Proxy)? o NONE Yes Decline to answer Patient/Responsible Party Signature: Reviewed by (office use): EMA Clipboard (office use): ROS/Med Rec (MA initial) Date: Date:
4 PRIVACY POLICY ACKNOWLEDGEMENT FORM The notice of privacy practice for the office of Illinois Dermatology Institute, LLC is available at the front desk and on our website at Should you wish to receive your own copy to take with you please ask our receptionist. The tice of Privacy Practices may change from time to time and you are welcome to request a revised copy at your next visit, call our office and request a copy, or mail a written request. Section 1 - Acknowledgement I acknowledge and understand the tice of Privacy Practices for the office Illinois Dermatology Institute, LLC Patient Name Date Date of Birth MRN (office use) Section 2 - tification and Emergency Designee I give permission to Illinois Dermatology Institute, LLC (IDI) and staff to perform the following duties to maintain continuity of care. Confirm/revise my appointment times by calling my home, business, and any other designated phone number. YES EJNO How would you like to receive your courtesy appointment reminders? (Please choose only one): El Text Phone call Leave a message of normal test result on my home answering machine or with a specified family member. YES E NO Discuss medical issues with members of your household EYES ENO The office and personnel are authorized to contact the party listed below to discuss and handle my medical care in the event of an emergency or to receive message information on my appointments and test results: Designated Person Contact Number Section 3 - Marketing communication IDI marketing consists of sharing new product, discounts or service information directly to you, our patient. The information may be communicated by letter, or . We do not sell your information to third party companies. I wish to opt IN and receive marketing and other communications via , phone calls, or letter. address: ID I wish to opt OUT / do not wish to receive marketing information. I understand the information provided to me in the privac notice and! have indicated my response to questions in each section. Patient Signature and Phone number Date
5 MRN: Today's Date: PATIENT INFORMATION Name Mailing Address: Last First Middle Street *Cell phone: ( (Preferred) address: City State Zip Code Home Phone: ( ) Work phone: ( Date of Birth: i / Last 4 of SS#: Marital status: Spouse's name: Age: Sex: Race: o Employed o FT Student o PT Student o Retired o Unemployed NAME OF RESPONSIBLE PARTY (If different from patient above): Mailing address of responsible party Street City State Zip Cell phone: ( ) Home: ( ) Date of Birth: Relationship: IN CASE OF EMERGENCY, NOTIFY: Phone: ( ) INSURANCE INFORMATION After completing this form, please bring it to the front desk along with your current insurance card and photo ID. PATIENT AUTHORIZATION I authorize the release of medical information to my primary care or referring physician and as necessary to process insurance claims, insurance applications, and prescriptions. I also authorize payment of medical benefits to the provider. I understand that Illinois Dermatology Institute uses photographs at times to ensure patient safety practices. I understand that Illinois Dermatology Institute does not permit taking videos, pictures, or audio recordings during any part of my care. I understand that backless chairs or chairs on wheels in the exam rooms are intended for use by providers or medical staff only. I understand that payment is required for all services at the time they are rendered (unless I participate in an insurance plan that IDI accepts where all applicable copayments will be collected at the time of service). It is the patient's responsibility to check to see if the IDI provider is in-network. I am responsible for knowing the policies of my insurance, such as: co-pay coinsurance, deductible, pre-existing conditions, policy exclusions, effective date, termination date, etc. Co-pays and self-pay procedures are due at the time of service, no exceptions. IDI accepts payment in the form of cash, credit card or check, I understand that if my check does not clear the bank, a $25 service fee will be automatically added to my account. I understand that any procedure performed in the office may be billed separately and in addition to the office visit fee and that as of January 2015, pathology is now billed separately from the path lab. I will do my best to notify the office if I am going to be late to my appointment and understand it will be up to the discretion of the IDI provider as to whether or not I will be seen if arriving more than 30 minutes late. I also understand that I am responsible for a $30 charge for all missed appointments that I did not cancel at least 24 hours in advance. For the consideration of other patients who want to be seen, if I repeatedly cancel less than 48 hours in advance or repeatedly no show for my appointments, I understand that IDI has the right to discharge me as a patient. My signature below signifies my understanding and willingness to comply with the above policies. Patient or responsible party's signature: Date: If patient is a minor, Print name of responsible party: Relationship:
6 ILLINOIS kv) DERMATOLOGY INSTITUTE OFFICE POLICIES 1. It is the patient's responsibility to check to see if their insurance is in-network. If your insurance policy requires a referral it is your responsibility to bring your referral to your office visit. Referrals are only valid for 90 days from the issue date and are only good for as many visits as your primary doctor has approved. You are responsible for knowing the policies of your insurance, such as copay, co-insurance, deductible, pre-existing conditions, policy exclusions, effective date, termination date, etc. Co-pays and self-pay procedures are due at the time of service, no exceptions. Each scheduled appointment in our office is considered an office visit and will be charged to your insurance. If a procedure is performed, it is an additional charge to your insurance. If a biopsy or excision is performed the specimen will be sent to the laboratory and read by a Dermatopathologist. There is an additional charge for the laboratory service by the lab. If you need to cancel and/or reschedule an office visit or surgery appointment, please notify our office no less than 24 hours in advance. if you cancel less than 24 hours in advance or no show, your account will be charged $30 or $100 respectively. If you need to cancel and/or reschedule a cosmetic procedure, please notify our office no less than 24 hours in advance. If you cancel less than 24 hours in advance or no show, your credit card on file will be charged $100. If you arrive more than 15 minutes late without calling our office, it will be up to the discretion of the practitioner to determine whether the appointment will need to be rescheduled. Patient Signature Date Patient Name (Printed) MRN
Illinois Dermatology Institute Patient Information (Please Print) Today s Date / /
Illinois Dermatology Institute Patient Information (Please Print) Today s Date // Name: Last First MI Mailing Address: Street City State Zip code Home Phone( ) Alternate Phone( ) Email Ok to leave message:
Maragh Dermatology. ( ) New Patient ( ) Name Change ( ) Address Change. Today s Date. Patient Name: Last First MI Male ( ) Female ( )
Maragh Dermatology ( ) New Patient ( ) Name Change ( ) Address Change Today s Date Patient Name: Last First MI Male ( ) Female ( ) DOB / / Marital Status ( ) Married ( ) Single ( ) Other Spouse Address
Illinois Dermatology Institute
Illinois Dermatology Institute PATIENT INFORMATION (Please Print) Today s _/ / Name: Last First M.I. Mailing Address: Street City State Zip Code Home Phone ( ) Work Phone ( ) Cell Phone ( ) OK to leave
Illinois Dermatology Institute
Illinois Dermatology Institute PATIENT INFORMATION (Please Print) Today s _/ / Name: Last First M.I. Mailing Address: Street City State Zip Code Home Phone ( ) Work Phone ( ) Cell Phone ( ) OK to leave
Patient Update Information
Patient Update Information Patient Name: Last First D.O.B If your info has not changed since your last visit, please sign the bottom of this page and all the consents for our yearly update! If any of the
Address: Primary Insurance Co. Name: Policy Holder:
Today s Date: / / PATIENT INFORMATION Name: Last First M.I. Mailing Address: Street City State Zip Code Home Phone: Work Phone: Cell Phone: OK to leave message: Yes No OK to leave message: Yes No OK to
Maragh Dermatology, Surgery, & Vein Institute
Maragh Dermatology, Surgery, & Vein Institute ( ) New Patient ( ) Name Change ( ) Address Change Today s Date Patient Name: Last First MI Male ( ) Female ( ) DOB / / Marital Status ( ) Married ( ) Single
Privacy Practices. Patient Name (please print) Patient Date of Birth. Signature of Patient/Guardian
Privacy Practices I acknowledge that Owensboro Dermatology Association, PSC has provided me a copy of their Notice of Privacy Practices, which provides a detailed description of the uses and disclosures
Patient Information (Please Print) Appt. Date / /
Patient Information (Please Print) Appt. Date / / Last name: First: MI: DOB: Address: Apt: City: State: Zip: Phone: E-mail address: Cell: SS#: Marital Status: Gender: M or F Responsible Party (If Different
If you have any questions about this payment method, do not hesitate to ask. Visa MasterCard American Express Discover Other:
To Our Patients: As you know if you have ever checked into a hotel or rental car, the first thing you are asked for is a credit card, which is imprinted and later used to pay your bill. This is an advantage
HIPAA Patient Consent Form
HIPAA Patient Consent Form Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. The Notice contains a Patient Rights section describing
Patient Registration Form
Patient Registration Form Name: Jr Sr Dr First Middle Last SS#: - - DOB: / / Sex: M F Primary Language: Race: Hispanic Non-Hispanic Decline E-Mail address: Is it okay to email you about upcoming cosmetic
PATI ENT INFORMATION Date=----~--- First Name: Ml: Last Name: ------------ Date of Birth: Sex: [ ] Male [ ] Female Address: City,State, Zip: Home Phone: Cell Phone:, Work Phone: Email Address: Marital
New Patient Form. Patient Name: DOB: Date: Sex: Race: Social Security Number: Driver s License Number: Address: City/ State/ Zip
New Patient Form Patient Name: DOB: Date: Sex: Race: Social Security Number: Driver s License Number: Address: City/ State/ Zip Phone (Primary) (Secondary) Email May we leave a detailed message on your
DERMATOLOGIC CENTER FOR EXCELLENCE ANTHONY S. DEE, MD DANIELLE JOHNSTON, RPA-C LISA PORTER, RPA-C PATIENT REGISTRATION FORM
PATIENT REGISTRATION FORM Date Patient Name: DOB: Sex: M F Address: City/State/Zip: Email: Social Security #: Please provide contact information and indicate your preferred contact number: Home Phone:
HIPAA Patient Consent Form
HIPAA Patient Consent Form Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. The Notice contains a Patient Rights section describing
PATIENT REGISTRATION INFORMATION Initial
PATIENT REGISTRATION INFORMATION Date Initial PATIENT S PERSONAL INFORMATION Please complete both sides of this form. Marital Status: Single Married Divorced Widowed Male Female Name: ( ) last name first
REGISTRATION FORM (Please Print)
REGISTRATION FORM (Please Print) Today s date: Primary Care Physician: PATIENT INFORMATION Patient s last name: First: Middle: q Mr. q Mrs. q Miss q Ms. Marital status (circle one) Single / Mar / Div /
Corederm Dermatology & Cosmetic Center
Please present ALL Insurance cards and Drivers License to the receptionist at every visit. Patient Information: Please Complete All Fields Using Legal Names of the Parties Involved. First name: Last name:
PATIENT INFORMATION: DATE: REFERRAL INFORMATION: INSURANCE INFORMATION: EMERGENCY CONTACT: PHARMACY INFORMATION:
PATIENT INFORMATION: DATE: Patient Name: Gender: DOB: Address: Preferred Phone Other Phone SSN: Occupation: Employer: Address: Phone#: REFERRAL INFORMATION: Who referred you to our practice? Who is your
If you have any questions about this payment method, do not hesitate to ask. Visa MasterCard American Express Discover Other:
To Our Patients: As you know if you have ever checked into a hotel or rental car, the first thing you are asked for is a credit card, which is imprinted and later used to pay your bill. This is an advantage
Medicare Patient Registration
Medicare Patient Registration Name: Jr Sr Dr First Middle Last SS#: - - DOB: / / Sex: M F Primary Language: Race: Hispanic Non-Hispanic Decline E-Mail address: Is it okay to email you about upcoming cosmetic
Financial Policy. Washington Square Dermatology Page 1
Financial Policy Washington Square Dermatology is committed to providing patients with the best possible care and assistance. Our financial policy explains each aspect of the billing process within our
PATIENT INFORMATION Please Complete All Sections on All Pages
PATIENT INFORMATION Please Complete All Sections on All Pages PREFERRED PHONE OK to leave message: Yes No ALTERNATE PHONE OK to leave message: Yes No We will utilize your preferred phone number to communicate
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
New Patient Information
New Patient Information Patient Title Dr. Mr. Mrs. Ms. Miss Last Name First Name M.I. Address Apt/Ste # City State Zip Date of Birth / / Age Male Female Home Phone Cell Phone Is it ok to leave a detailed
Please Complete All Sections on All Pages. RELEASE OF MEDICAL INFORMATION to other individuals if we are unable to reach you (HIPAA requirements)
Please Complete All Sections on All Pages PREFERRED PHONE # ALTERNATE PHONE #_ EMAIL ADDRESS BIRTH DATE PATIENT S NAME: (Last, First, MI) SEX: PRIMARY ADDRESS (STREET) APT# CITY STATE ZIP -- ALTERNATE
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:
615 1 st Street North, Alabaster 1320 Woodfin Lane, Clanton Phone: (205) Fax: (205)
615 1 st Street North, Alabaster WELCOME TO TRUE DERMATOLOGY. PLEASE FILL OUT ALL PERTINENT SECTIONS AND SIGN WHERE INDICATED. TODAY S DATE: / / Last Home Phone#: Check Preferred Contact Number First M.
NEW PATIENT FORM (please print)
NEW PATIENT FORM (please print) PATIENT INFORMATION Full Name: Male: Female: First Middle Last Street Address: City: State: ZIP: Home Phone: Work Phone: Cell: Birthdate: Occupation: How were you referred:
Patient Name: Todays Date: Patient Name Age Date of Birth / / SS# - - Sex: M F Marital Status
Patient Name: Todays Date: *General Patient Information Patient Name Age Date of Birth / / SS# - - Sex: M F Marital Status Email Phone: Home ( ) - Cell ( ) - Mailing- Address, City, State & Zip *PARENT
Patient Information Please Complete All Sections. Responsible Party, if different from patient. In Case of Emergency. Name (Last, First, M.
Patient Information Please Complete All Sections Name (Last, First, M.I) Nickname Date of Birth / / SS# Gender: Male Female Home Address (street, city, state, zip) 2 nd Mailing address (street, city, state,
PATIENT INTAKE FORM. UNDER 18 years old?: INSURANCE INFORMATION (Please give your insurance card to the receptionist.)
PATIENT INTAKE FORM Primary Care Physician: Specialist Physician: Referred? : Referred By: PATIENT INFORMATION (Please give your I.D. to the receptionist.) Patient s FIRST Name: LAST Name: MI: Preferred
Last Name _ First Name Middle Initial _ Social Security Number: Birthdate Age Sex (Circle one) M F Address _City State Zip Home Phone # Cell Work
Last Name _ First Name Middle Initial _ Social Security Number: Birthdate Age Sex (Circle one) M F Address _City State Zip Home Phone # Cell Work Marital Status (circle one) Single Married Separated Divorced
New Patient Registration
New Patient Registration Today s Date: e-mail: Patient Information First Name M.I. Last Name Address City State Zip Phone Work Cell Date of Birth Age SSN Occupation Employer Language English Spanish Other
INSURANCE INFORMATION: This information is REQUIRED
4566 Hwy 20 E, Suite 101 301 Medical Drive, Suite B Niceville, FL 32578 Andalusia, AL 36420 (850) 897-7546 (334) 222-7546 PATIENT INFORMATION: Complete with PATIENT Information First Name: Last: M.I.:
VALLEY DERMATOLOGY, LLC 2611 West Main Street, Ste 1 Waynesboro, VA Fax:
VALLEY DERMATOLOGY, LLC 2611 West Main Street, Ste 1 Waynesboro, VA 22980 540-221-6702 Fax: 540-221-6704 PATIENT DEMOGRAPHICS Patient Name: Birth Gender: Male or Female DOB: Social Security Number: Guarantor
BIRCH BAY DERMATOLOGY
BIRCH BAY DERMATOLOGY PATIENT INFORMATION Photo ID (State or Federal) Please provide this to the receptionist PATIENT REGISTRATION FORM By providing your contact information below, you are granting permission
NEW PATIENT INFORMATION (PLEASE PRINT)
NEW PATIENT INFORMATION (PLEASE PRINT) PATIENT'S SS# DATE PATIENT'S NAME HOME PHONE NO. MAILING ADDRESS CITY, & STATE ZIP EMAIL MALE FEMALE DATE OF BIRTH AGE MARITAL STATUS: SINGLE or MARRIED PATIENT'S
Patient Information Please Complete All Sections. Responsible Party, if different from patient. In Case of Emergency. Name (Last, First, M.
Patient Information Please Complete All Sections Name (Last, First, M.I) Nickname Date of Birth / / SS# Gender: Male Female Home Address (street, city, state, zip) 2 nd Mailing address (street, city, state,
REGISTRATION FORM (Please Print)
CENTRAL FLORIDA DERMATOLOGY, ALFREDO E. GONZALEZ, MD, PA REGISTRATION FORM (Please Print) Primary Care Physician: PATIENT INFORMATION Patient s last name: First: Middle: Mr. Mrs. Miss Ms. Marital status
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:
PATIENT INFORMATION FORM
PATIENT INFORMATION FORM APPOINTMENT DATE & TIME Name Nickname Address: _ STREET CITY STATE ZIP Phone: HOME CELL WORK Date of Birth: Age: Sex: Marital Status: Email: @ Do you wish to receive email/text
Office Location and Directions
Office Location and Directions Our office is located at 395 Commercial Court, Suite E, Venice, FL 34292 off Jacaranda near I-75, exit # 193. Turn at traffic light with Hess gas station and McDonald's on
Get Serious About Your Skin
PATIENT INFORMATION: Today s Date First Name Last Name Middle Address Apt. City State Zip E-Mail Address Home Phone ( ) Work Phone ( ) Cell Phone ( ) Date of Birth Age Social Security Number Sex: o M o
Pierre G. Labrecque, M.D. 120 North Miller Street, Building C Santa Maria, CA (805) Office (805) Fax
(805) 739-0033 Office (805) 739-1712 Fax Welcome to DermaSpa MED and thank you for entrusting us with your medical needs. Your care and satisfaction is our priority and we are committed to providing you
Name SS# LAST FIRST MIDDLE INITIAL. Address STREET CITY APT # STATE ZIP. Alternate Address STREET CITY STATE ZIP
Date: Patient Information Name SS# LAST FIRST MIDDLE INITIAL Date of Birth Gender Male Female Marital Status Single Married Divorced Widowed Address STREET CITY APT # STATE ZIP Alternate Address STREET
Office Location and Directions
Office Location and Directions Our office is located at 395 Commercial Court, Suite E, Venice, FL 34292 off Jacaranda near I-75, exit # 193. Turn at traffic light with Hess gas station and McDonald's on
PATIENT INFORMATION. Race: Ethnicity:
PATIENT INFORMATION Last name: First: MI: Today s Date: SS#: Mailing Address: Date of Birth: City: State: Zip: Sex: Primary Phone: Home Work Mobile Secondary Phone: Home Work Mobile Tertiary Phone Home
PATIENT REGISTRATION (Please Print)
PATIENT REGISTRATION (Please Print) DATE: PATIENT INFORMATION Patient s Name: SS #: (First) (Middle) (Last) Street Address: Apt. #: Male 9 Female 9 Age: Patient s Date of Birth: Home ( ) Cell ( ) Email
Friendswood Dermatology REGISTRATION INFORMATION Page 1-2. Name First MI Last
Friendswood Dermatology REGISTRATION INFORMATION Page 1-2 Patient Information: Today s Date Name First MI Last Address Street City State Zip Home Phone ( ) Work Phone ( ) Cell Phone ( ) Email: @ Birth
PATIENT REGISTRATION
PATIENT REGISTRATION Legal Name: Billing Address: Last First Middle Initial Street City/State Home Phone #: Cell Phone #: Work Phone #: Birthdate Zip Code How would you like to receive appointment reminders?
Metrolina Dermatology and Skin Surgery Specialists Park Road, Suite 100 Charlotte, NC
Metrolina Dermatology and Skin Surgery Specialists 10502 Park Road, Suite 100 Charlotte, NC 28210 www.metrolinadermatology.com Dear Patient, We thank you for choosing Metrolina Dermatology and Skin Surgery
Are you interested in receiving information about special promotions? Yes! No thanks.
1600 N Coalter St, Ste 19 Staunton, VA 24401 Phone: 540-885-4500 Fax: 540-885-4600 PATIENT DEMOGRAPHIC INFORMATION PLEASE PRINT NAME: AGE: (LAST) (FIRST) (MIDDLE) SEX: M F (CIRCLE) DATE OF BIRTH: PERSON
Date. Cell Phone: ( )
Date / / Name: Date of Birth: / / AGE: Last First MI Home Address: City: State: Zip: 2 nd Home Address: City: State: Zip: Email Address: Home Phone: ( ) Work Phone: ( ) Cell Phone: ( ) Is it okay to leave
Pierre G. Labrecque, M.D. 120 North Miller Street, Building C Santa Maria, CA (805) Office (805) Fax
120 North Miller Street, Building C Santa Maria, CA 93454 (805) 739-0033 Office (805) 739-1712 Fax Welcome to DermaSpa MED and thank you for entrusting us with your medical needs. Your care and satisfaction
PATIENT INFORMATION SHEET. Reason(s) for Visit: (chief complaint)
PATIENT INFORMATION SHEET Patient : Pharmacy: Date of Birth: Pharmacy Phone Number: Reason(s) for Visit: (chief complaint) Past Medical History: (Check all that apply) Anxiety Arthritis Asthma Atrial Fibrillation
PATIENT REGISTRATION
PATIENT REGISTRATION Legal Name: Last First Middle Initial Billing Address: Street City/State Home Phone #: Cell Phone #: Work Phone #: Birthdate Zip Code How would you like to receive appointment reminders?
PATIENT INFORMATION SHEET. Reason(s) for Visit: (chief complaint)
PATIENT INFORMATION SHEET Patient : Pharmacy: Date of Birth: Pharmacy Phone Number: Reason(s) for Visit: (chief complaint) Past Medical History: (Check all that apply) Anxiety Arthritis Asthma Atrial Fibrillation
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
This form should be filled out completely
This form should be filled out completely Patient Name First Name Middle initial Last Name (Circle One) Male Female Date of Birth Address / Street Address City State Zip Code Phone # s Home _ Work _ Cell
NEW PATIENT REGISTRATION FORM
NEW PATIENT REGISTRATION FORM Date: / / Patient (Legal) Name: Nickname: SSN (>Age 18): Date of Birth: Sex:! Male! Female Driver s License #: State: Mailing Address: (Street/PO Box, City, State, Zip Code)
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
19910 S. Tamiami Trail, Suite B Hillary Cachet, PA-C Estero, FL (239)
FLORIDA COASTAL DERMATOLOGY ASSOCIATES Naples 801 Anchor Rode Dr., Suite 100 Lisa D. Zack, M.D Naples, FL 34103 Bradley T. Kovach, M.D. (239) 263-1717 Janalea Thomas, PA-C Estero Lidia Starr, PA-C 19910
If have a specialist co-pay, we will collect that at time of service.
Metrolina Dermatology and Skin Surgery Specialists 10502 Park Road, Suite 100 Charlotte, NC 28210 www.metrolinadermatology.com Phone: 980-299-3926 Dear Patient, We thank you for choosing Metrolina Dermatology
NEW PATIENT FORM (please print)
NEW PATIENT FORM (please print) PATIENT INFORMATION Full Name: Nickname: First Middle Last Social Security Number (SSN): Birthdate: Age: Male: Female: Street Address: City: State: ZIP: Home Phone: Work
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
(Last) (First) (Middle) Home Phone: Work: Cell: (Include Extension, if applicable) (OK to Text )
JEFFREY S. GREENWALD, M.D. MICHAEL S. HENNER, M.D. ROBERT W. DEMETRIUS, M.D. KEMKA S. OGBURIA, M.D. DINAH M. WARNER, M.D. KATHLEEN B. ZENDELL, M.D. STEVEN M. PRICE, M.D. EDWARD J. POSNAK, M.D. ASHLEY R.
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
PATIENT INFORMATION AND ACKNOWLEDGEMENT OF PRIVACY NOTICE RECEIPT
PATIENT INFORMATION AND ACKNOWLEDGEMENT OF PRIVACY NOTICE RECEIPT 1. Patient s Name Last First MI Address Street & Apt # City State Zip Home Phone Cell Phone Other Phone Email Address: Age Birthdate /
Would you like to receive our monthly ed newsletter? Yes! No thanks.
Phone: 540-885-4500 Fax: 540-885-4600 PATIENT DEMOGRAPHIC INFORMATION PLEASE PRINT NAME: AGE: (LAST) (FIRST) (MIDDLE) SEX: M F (CIRCLE) DATE OF BIRTH: PERSON RESPONSIBLE FOR ACCOUNT: MAILING ADDRESS: (CITY)
PATIENT INFORMATION. Patient s last name: First: Middle: Marital status:
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/
We look forward to meeting you soon!
Dear New Client: We are pleased to welcome you to our practice! Thank you for allowing us to serve your health care needs. We are enclosing with this letter our new patient information forms. Please complete
PATIENT REGISTRATION FORM. _Apt#:. _Apt#:.
1C SAKAMOTO, M,D, QUEENS PHYSICIANS OFFICE BHDG III 1 650- S, BERETANIAST. -SU1TC 603 HONQUJLU.HI 'S6B13 PR; (808) 447-7454 FAX'; {80S) 447-7458 PATIENT REGISTRATION FORM Patient Name: Date of Birth: Gender:
PATIENT INFORMATION Date
PATIENT INFORMATION Date Please Complete All Sections Legal Name of Patient Age (Last) (First) (Middle) Date of Birth SSN Gender Marital Status Mailing Address (Street/PO Box) (Apt#) (City) (State) (Zip)
Welcome to our practice!
Welcome to our practice! We appreciate the opportunity to care for your skin! The office is open Monday-Friday 8:00am-5:00pm. We see all patients on an appointment basis and ask that you call in advance
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
Mailing / Secondary/ Billing/Guardian/POA address (circle one) City/State/Zip. Home Phone# Cell Phone# Phone Relationship INSURANCE INFORMATION
Welcome to Bracciano Dermatology! Please fill out the information below prior to your visit. We recommend you complete this information online at our patient portal http://www.premierdermdocs.ema.md. Please
Soderma Dermatology. General, Surgical & Cosmetic
S D General, Surgical & Cosmetic Welcome to Soderma, General, Surgical & Cosmetic Dermatology. We are a comprehensive dermatology practice, providing a full range of medical, surgical and cosmetic dermatologic
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
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
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
REGISTRATION/CONSENT FORM
Today s Date: REGISTRATION/CONSENT FORM (PLEASE PRINT) PATIENT INFORMATION Patient s last name: First: Middle: Mr. Mrs. Miss Ms. Is this your legal name? If not, what is your legal name? (Former name):
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
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
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
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
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
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
Financial Policy. 158 Front Royal Pike Suite 303 Winchester, VA (540) Office * (540) Fax. 103 W. South St.
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
Continued on Reverse Side
PATIENT REGISTRATION FORM Date Male Female First Middle Last Email Address Mailing Address City State Zip Code Home Phone Work Phone Cell Phone Social Security Date of Birth Ethnicity: Hispanic or Latino
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
CENTER CITY DERMATOLOGY STEPHEN HESS, M.D., Ph.D. MEDICAL HISTORY
CENTER CITY DERMATOLOGY STEPHEN HESS, M.D., Ph.D. MEDICAL HISTORY Name Age Date of Birth Email _ Reason for today s visit Who referred you to this office _ Who is your primary care physician? Are you allergic
Mailing Address: Name: FIRST MIDDLE LAST. Mailing address: If different from patient. Telephone Numbers: Home Day Number
Dermatology Center South PC 2800 Ross Clark Circle, Suite 2 DOTHAN, ALABAMA 36301 REGISTRATION FORM FOR DEPENDENTS] Patietnt Name: First Middle Initial Last of Birth: / / Sex: Male Female Month Day Year
Demographic Information
Demographic Information Name: Last First Female Male DOB: / / Age: Race: Caucasian American Indian or Alaska Native Asian African American Native Hawaiian or Other Pacific Islander Other Ethnicity: Hispanic
GWINNETT DERMATOLOGY, P.C. PATIENT REGISTRATION
PATIENT INFORMATION (PLEASE PRINT LEGIBLY) GWINNETT DERMATOLOGY, P.C. PATIENT REGISTRATION LAST NAME FIRST NAME, MI PREFERRED NAME DATE OF BIRTH GENDER Male Female STREET ADDRESS CITY, STATE, ZIP CODE
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,
History and Intake Form. Date of Birth:
History and Intake Form Name: Date of Birth: Name I prefer to be called: Past Medical History: (please check all that apply) Anxiety Arthritis Asthma Atrial fibrillation (irregular heartbeat) BPH Bone
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:
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