Street Address Apt. No. City State Zip. Race: Ethnicity: Hispanic Not Hispanic or Latino. Marital Status: Single Married Widowed Divorced

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Verity Berry
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1 Patient Information MRN# Patient Name: Address: Street Address Apt. No. City State Zip Age: Birthdate: *Social Security: Phone:Home# Work # Cell # Gender: Male Female Primary Language: Race: Ethnicity: Hispanic Not Hispanic or Latino Marital Status: Single Married Widowed Divorced Who referred you? (mandatory) Last First Primary Care Physician: Phone: Phone: Emergency Contact: Relationship to patient: Phone: Home Work Other May we leave information on your answering machine, voic , and/or ? Yes No (Specify instructions): May we photograph you for the medical chart? Yes No Name of Policy Holder: Policy Holder s Birth Date: *Policy Holder s Social Security Relationship to policy holder: Self Spouse Child or Dependent Other: Signature: Date:

2 Patient Consent to Treatment & Financial Responsibility I am at least 18 years of age or, if not, I am accompanied by a legal guardian. I hereby consent to and authorize an examination by my doctor and such assistant or staff as may be assigned by the physician. I authorize the Innovative Dermatology, PA to fax my records to any physician or pharmacy for the purpose of coordinating or managing my healthcare. We have contracts with many insurance companies to accept assignment of benefits for our services. In order to do this we must have a valid insurance card and a driver s license or other legal form of identification at the time of the visit or you will be charged as a private pay patient. You are responsible for knowing your insurance coverage and benefits. Your co-pay and any deductible are expected at the time of your visit. We accept Cash, Visa, MasterCard and Checks. As a service to you, we will file your insurance claim. You will be billed for any amount not covered by the insurance company, including deductibles, surgical/pathology deductibles and co-insurance. Payment is due upon receipt of your statement. For cosmetic services not covered by health insurance, I understand that charges are payable on or before the day service is rendered. I understand that photography is at times a necessary part of planning and evaluating treatment, and hereby authorize the taking of photographs at the direction of the physician and/or delegate, solely for documentation purposes and recognize they will be kept confidential unless otherwise disclosed. Innovative Dermatology, PA shall be entitled to recover any losses or damages it may suffer by reason of a failure of the patient and/or responsible party to pay charges when they become due, including, but not limited to, reasonable attorney fees, plus costs of enforcing this agreement. Any amounts overdue for more than thirty (30) days shall accrue interest at the rate of 1.5% per month. I request that payment of Medicare or other insurance company benefits be made to Innovative Dermatology for services provided. I authorize the release of any information needed for processing of this or any related claim/s. I will permit a copy of the authorization to be used in place of the original, and request payment of medical insurance benefits to the party who accepts assignment. I understand that all outside laboratory testing will be billed from the specific laboratories to me and/or my insurance company. I accept payment responsibilities if my insurance denies payment. A copy of this authorization shall be considered as valid as the original. I acknowledge I have read this information thoroughly and understand this patient financial responsibility form. We ask you to show consideration by notifying our office at least 24 hours in advance if you are unable to keep an appointment. We would like to have the option to offer that appointment to another patient who needs to see the doctor. If you fail to give us a 24-hour notice of cancellation, there will be a $50 cancellation fee ($100 fee for surgical procedures) billed to your account that is not covered by your insurance. You will bear complete financial responsibility for this fee. We value you as a patient and hope not to encounter this problem, as we feel it could hinder your ability to receive proper medical care. Signature: Date: Relationship to the patient (If other than patient)

3 HIPAA 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 your rights under the law. You have the right to review our Notice (copy available upon request) before signing this Consent. The terms of our Notice may change. If we change our Notice, you may obtain a revised copy by contacting our office. You have the right to request that we restrict how protected health information about you is used and disclosed for treatment, payment, or health care operations. We are not required to agree to this restriction, but if we do, we shall honor that agreement. By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment, and health care operations. You have the right to revoke this Consent, in writing, signed by you. However, such a revocation shall not affect any disclosures we have made on reliance on your prior Consent. The Practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). As of September 26, 2013, an updated copy of our Privacy Act is available for review. The patient understands that: Protected health information may be disclosed or used for treatment, payment, or health care operations. The Practice has a Notice of Privacy Practices and that the patient has the opportunity to review this Notice. The Practice reserves the right the change the Notice of Privacy Practices. The patient has the right to restrict the uses of their information but the Practice does not have to agree to those restrictions. The patient may revoke this Consent in writing at any time and all future disclosures will then cease. The Practice may condition receipt of treatment upon the execution of this Consent. *Do you give us permission to discuss your medical record with anyone? (specify name, DOB, & relationship): Signature: Date: Relationship to the patient (If other than patient) *Social security numbers are needed for insurance verification purposes. Not all insurance companies require us to have a social security number on file. However, if your insurance company denies a claim for any reason concerning inability to identify the patient, you will be responsible for the unpaid services. Signature: Date:

4 MRN: COSMETIC INTEREST QUESTIONNAIRE Innovative Dermatology prides ourselves on providing you with complete dermatology care. We offer a variety of aesthetic services to meet your needs. In order to better serve you, please complete the questionnaire below with the services you would like to discuss with the provider. Cosmetic Interest Questionnaire Date: Date of Birth: Patient Name: Would you like to subscribe to our newsletter? Address When I look in the mirror, I am not concerned, somewhat concerned, or very concerned about the appearance of my wrinkles. Not Concerned Somewhat Concerned Very Concerned I am interested in a skincare routine that is most appropriate for my skin type and age. YES NO THANKS I am interested in learning about anti-aging products and or procedures. YES NO THANKS Please indicate the aesthetic treatments and procedures that interest you. Please check all that apply: Skin Tightening/Double Chin Facial redness Length/fullness of eyelashes Facial /Leg Veins removal Sun spots/age spots/freckles Sun damage to neck and decollete Topical wrinkle treatments Facial Treatments Dermal fillers for fine lines and wrinkles Botox (Botulinum toxin A) Skin Rejuvenation/Resurfacing Anti-Aging (Face/Neck/Hands) Professional skin care products for your specific skin type Signature: Date: Innovative Dermatology, PA Innovative Dermatology, PA 5425 West Spring Creek Parkway, Suite Independence Parkway, Suite 150 Plano, Texas, Plano, Texas, Tel: Tel:

5 MRN: MEDICAL HISTORY FORM Today s date: Referred By: PATIENT INFORMATION Last Name: First First: Name: Middle: Middle: Birth date: Birth date: / / Pharmacy: Pharmacy Phone Number: Pharmacy Address: REASON FOR TODAY S VISIT THIS PORTION MUST BE FILLED OUT Chief Concern: (be specific) Location of concern: Duration: Prior Treatments: Adhesive tape allergy Yes No Abnormal scars Yes No Latex allergy Yes No Poor wound healing Yes No Local anesthetics allergy Yes No HSV / cold sore Yes No Epinephrine sensitivity Yes No Eczema Yes No Bacitracin allergy Yes No Asthma Yes No Neosporin allergy Yes No Hay fever Yes No Anticoagulant treatment Yes No Heart disease Yes No Bleeding disorders Yes No Diabetes Yes No Artificial joint Yes No Kidney disease Yes No Artificial heart valves Yes No Thyroid disease Yes No Organ transplant Yes No CLL Chronic leukemia Yes No Pre-op/ dental antibiotics Yes No Pacemaker / defibrillator Yes No Memory problems Yes No Lupus Yes No Fainting / syncope Yes No Mitral valve prolapsed Yes No Hepatitis Yes No Arthritis Yes No HIV positive Yes No Immunosuppressed Yes No MRSA Yes No Psoriasis Yes No Patient Signature Date

6 MRN: PERSONAL HISTORY Do you have a history of melanoma? Yes No Do you have a history of other skin cancer(s) Yes No Is there a history of melanoma in your family? Yes No Do you have a family history of other skin cancer(s) Yes No CURRENT MEDICATIONS MEDICATION ALLERGIES Do you have any medication allergies: Yes No List allergies and reaction: Are you pregnant? Yes No Are you breast feeding? Yes No Are you on birth control? Yes No Do you have regular menstrual cycles? Yes No List past surgeries: FOR WOMEN ONLY SURGICAL HISTORY SOCIAL HISTORY Do you use tobacco? Yes No Alcohol consumption? Yes No Do you use sunscreen? Yes No If so, what SPF is used? Current or previous tanning bed use? Yes No ADDITIONAL SYMPTOMS Easy Bruising Yes No Eye Irritation Yes No Fever Yes No Chronic Cough Yes No PT Constipation # Yes No Chills Yes No Abdominal Pain Yes No Weight Loss Yes No Anxiety Yes No Nausea/Vomiting Yes No Rash /Itchy Yes No Fatigue Yes No Shortness of Breath Yes No Blood Clots Yes No Joint Pain Yes No Swollen Lymph Nodes Yes No Depression Yes No Headache Yes No Diarrhea Yes No Patient Signature Date

Patient Information. Patient Medical Insurance

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