Medical Information. Past Surgeries. Skin History
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- Ellen Pearson
- 6 years ago
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1 Name: of birth: : Referred by: ( )*Physician ( ) Patient to Patient ( ) Family ( ) Insurance ( ) Internet ( ) Other: *If referred by physician please give name: Phone: First Last Who is your Primary care Physician? Phone: First Last Preferred Pharmacy: Phone: Address: Chief Complaint What is the reason for your visit today? What are your symptoms? What area(s) is affected? How long have you had the problem? What have you used to treat the problem? Medical Information Select any of the following medical conditions that you currently have: OR ( ) none apply to me ( ) Anxiety ( ) COPD(Chronic Obstructive Pulmonary Disease ) ( ) Hypertension(High Blood Pressure) ( ) Prostate Cancer ( ) Arthritis ( ) Coronary Artery Disease ( ) HIV/AIDS ( ) Radiation Treatment ( ) Asthma ( ) Depression ( ) Hypercholesterolemia ( ) Seizures ( ) Atrial Fibrillation(Irregular Heart Beat) ( ) Diabetes ( ) Hyperthyroidism ( ) Stroke ( ) Bone Marrow Transplant ( ) End Stage Renal Disease ( ) Hypothyroidism ( ) Other: ( ) BPH(Benign Enlargement of the Prostate ) ( ) Gerd(Gastro esophageal Reflux Disease) ( ) Leukemia ( ) Breast Cancer ( ) Hearing Loss ( ) Lung Cancer ( ) Colon Cancer ( ) Hepatitis, Type: ( ) Lymphoma When was your last Flu shot? Have you had a Pneumonia Vaccine? YES NO List all previous surgeries OR ( ) none apply to me: Past Surgeries Skin History Have you had any of the following skin conditions? OR ( ) none apply to me ( ) Acne ( ) Dry skin ( )Poison Ivy ( ) Actinic Keratosis ( ) Eczema ( ) Precancerous Moles ( ) Asthma ( ) Flaking or itchy scalp ( ) Psoriasis ( ) Blistering sunburns ( ) Hay fever/allergies ( ) Other: Personal History of Skin Cancer Personal History of Sun Exposure Family History of Skin Cancer ( ) Basal Cell Carcinoma Do you wear sunscreen daily? ( ) Yes ( ) No ( ) Basal Cell Carcinoma ( ) Squamous Cell Carcinoma If yes, what SPF? ( ) Squamous Cell Carcinoma ( ) Melanoma Do you tan in a tanning salon? ( ) Yes ( ) No ( ) Melanoma ( ) Unsure Multiple blistering sunburns as a child? ( ) Yes ( ) No ( ) Skin cancer, unsure what type ( ) No History of Skin Cancer History of atypical moles? ( ) Yes ( ) No If yes, which family member? ( ) No family history of skin cancer
2 Medication History List all current medications and vitamins: List allergies to prescription and non-prescription medicines: Social History ( ) Never smoked ( ) Current smoker ( ) Quit, former smoker ( ) Never drink alcohol ( ) Drink Socially (<1 daily) ( ) Drink Daily (1+ daily) In the past year, how many times have you had 5 or more drinks in a day? Review of Systems and Alerts Please check YES or NO in the box provided for all symptoms you are CURRENTLY EXPERIENCING. Hematologic/Lymphatic No to All Endocrine No to All Gastrointestinal No to All Problems with Bleeding Thyroid Problems Nausea or Vomiting Swollen Glands Excessive Thirst Heartburn Tender Glands Eyes No to All Increasing Constipation Anemia Redness Persistent Diarrhea Transfusion Pain Blood in Stool or Black Stool Integumentary - Skin No to All Double Vision Tightness or Abdominal Pain Problems with Healing Blurred Vision Jaundice Problems with Scarring Easy Bruising Ears/Nose/Mouth/Throat No to All Genitourinary No to All Redness Ringing in Ears Pain/Burning on Urination Rash Runny Nose Blood in Urine/Cloudy Hives Sores in Mouth Smoky Urine Itching Dryness in Mouth Discharge from Penis/Vagina Sun Sensitive Frequent Sore Throat Getting up at Night to pass Urine Tightness Difficulty Swallowing Vaginal Dryness Nodules/Bumps Hoarseness Rash/Ulcers in Genital Area Hair Loss Color Changes - Hands/Feet Allergic/Immunologic No to All Cardiovascular No to All Musculoskeletal No to All Frequent Sneezing Sudden onset Chest Pain Morning Stiffness Susceptibility to Infection Sudden Changes of Heart Beat Joint Pain Immunosuppression High Blood Pressure Muscle Weakness Hay Fever Swollen Legs or Feet Muscle Tenderness Joint Swelling Constitutional No to All Respiratory No to All Neurological/Psychiatric No to All Fever, Chills or Shakes Cough Headaches Night Sweats Shortness of Breath Dizziness Unintentional Weight Gain Wheezing Fainting Unintentional Weight Loss Anxiety Depression ALERTS ALERTS ALERTS Allergy to Adhesive Artificial Heart Valve Pacemaker Allergy to Lidocaine Artificial Joints within 2 Years MRSA/Staph Allergy to Antibiotic Ointments Blood Thinners Premedication Prior to Procedures History of Blood Clots Defibrillator Rapid Heartbeat with Epinephrine Pregnancy and Childbearing Information for Women Only Are you pregnant? Planning on becoming pregnant soon? Are you breastfeeding? Agitation Are you on some form of birth control? If yes, what form?
3 PATIENT REGISTRATION Please Complete All Fields : Patient Name: of Birth: Marital Status: First Last Address: City: State: Zip: Street/Apt #/PO Box *Preferred Phone#: ( ) Home: ( ) Cell: ( ) Work: Sex: F M SSN: Preferred Language: Race: ( ) White ( ) Black/African American ( ) Asian ( ) American Indian or Alaska Native ( ) Native Hawaiian/Pacific Islander ( ) Other: Ethnicity: ( ) Hispanic ( ) Non-Hispanic/Non-Latino ( ) Other/Non-determined Your visit today may include labs, cultures and/or skin biopsies. We generally receive results of lab work/cultures in approximately 3-5 business days and skin biopsy results in 7-10 business days. We will call you with results and any additional information prescribed by your physician. For BENIGN/NEGATIVE results on any tests listed above: ( ) YES, you may leave a detailed message informing me of my results at the following telephone # ( ) NO, do not leave a detailed message. Please leave call back information only on my voic . Employer: Occupation: Emergency Contact: Name: Relationship to Patient: Home #: Cell #: Work #: Person Responsible for Payment or Insurance subscriber (If different from above): Name: Relationship to Patient: Address: City: State: Zip: Street/Apt #/PO Box Home #: Cell #: Work #: SSN#: of Birth: Primary Insurance Co.: Phone #: Policy # Group #: Secondary Insurance Co.: Phone #: Policy # Group #:
4 Acknowledgement of Receipt of Notice of Privacy Practices (HIPAA) I hereby acknowledge that I have received a copy of North Dallas Dermatology Associates Notice of Privacy Practices. I have been given the opportunity to review, understand and consent to this practice s Notice of Privacy Practices as written. The Notice of Privacy Practices provides detailed information about how the practice may use and disclose my confidential information. Printed Name of Patient Signature of Patient or Legal Representative (if applicable) Relationship to Patient (If applicable) Parent or guardian of unemancipated minor Court appointed guardian Executor or administrator of decedent s estate Power of attorney Authorization for Use and Verbal Disclosure of Protected Health Information **This is not a medical release form for Physicians there is a different form for that request** I hereby authorize North Dallas Dermatology Associates to use and/or disclose my protected health information as described below to: Name and relationship to recipient(s) (friends/family only not physicians): 1. Relationship: Phone #: 2. Relationship: Phone #: 3. Relationship: Phone #: ( ) All Medical information, including but not limited to: appointments, billing, test results, diagnosis, and procedures. ( ) Only the following type of information: ( ) DO NOT disclose any information on file other than to patient. VALID ONE YEAR FROM DATE SIGNED. Signature of Patient or Responsible Party Consent for treatment of minor child *Please note that you may disregard the notice below if this does not pertain to the patient* I, being the parent or guardian of, in my absence do hereby request and authorize North Dallas Dermatology Associates permission to administer care as necessary. I authorize the following person/persons to authorize medical treatment for my child by North Dallas Dermatology Associates. I understand that I am responsible for services rendered for treatment and payments authorized by my personal representatives. If I choose to terminate the authorization of this form, I understand I must do so in writing. VALID ONE YEAR FROM DATE SIGNED. NAME OF PERSON ACCOMPANYING PATIENT (Excludes parent/legal guardian) Parent/Guardian name: Relationship to Child: Relationship to Patient Signature: _ : _
5 Financial Policy Thank you for selecting our practice for your dermatological needs. Our goal is to provide you with the highest quality of treatment and service. Your complete understanding of your financial responsibilities is an essential element of your care. If you have any questions about the following policy, please do not hesitate to ask our staff. Effective January 1st, 2016 all copays, deductibles and co-insurance are due at the time services are rendered. Please be aware that we collect an estimated payment on a few of these procedures at the time of check out (please refer to our Procedure Price List* below for details). If after submitting an in-network claim, including secondary insurance and you have already met your deductible elsewhere and should your insurance pay any portion of or all charges we will refund your payment upon receipt of your insurance payment. In the event your health plan determines a service to be not covered, or if we do not have an authorization on file prior to the appointment or you do not inform us of an insurance change you will be responsible for the complete charge at time services are rendered. We encourage our patients to understand their policy and to contact their insurance provider for clarification of benefits prior to services being rendered. You may receive a separate bill for laboratory or pathology services from an off-site lab for any tests your physician may order. Please discuss any billing errors or discrepancies with that laboratory. Please note that you may disregard this notice if you are a Medicare recipient or a self-pay patient. Procedure Price List Biopsy of a skin lesion $125 for the 1st Each additional biopsy $40 each additional *Destruction of an actinic keratosis/precancerous lesions $75 - $175 *Destruction of a wart, molluscum, or other benign lesion $102 - $125 *Excision of a skin lesion $90 - $385 *Sugical repair of the above listed skin lesion(s) $185 - $425 *Prices vary depending in size and numb er of lesion(s) Cancellation, missed appointments and late arrivals Skin Health SPA* Returned check fee Collection fee Other Miscellaneous Fees If we do not receive 24 hour notice there will be a $30.00 cancellation/no show fee billed. Patients with multiple cancellations or missed appointments also may be discharged from our practice. In an event that you are running late, please call our office. If you are more than 15 minutes late to your scheduled appointment, you may be asked to reschedule. *Please note Our cancellation/no show policy differs from our general office policy. Due to the extended appointment times, our charges are based on time allotted for your specific treatment. Please ask for details or see our cosmetic consultant for details. There will be a $30.00 charge for all returned checks. If your account is turned over to our collection agency, you will be responsible for the collection fee charged to us by the agency in addition to your outstanding balance. Notice to parents with children under age 18 (when applicable): In cases of divorce or separation, the parent authorizing treatment for a child will be the parent responsible for any charges. If a divorce decree requires the other parent to pay all or part of the costs, it is the authorizing parent s responsibility to collect from the other parent. We accept Cash, Checks, MasterCard, Visa, Discover, American Express and Care Credit. I have read and understand the financial policy, and I agree to be bound by its terms. I understand and agree that such terms may be amended in the future by the practice. Printed Name of Patient Signature of Patient or Responsible Party of Birth
6 **Optional** Credit Card Save on File For your convenience and as an option, we kindly request that you leave a credit card on file which may be used to reduce your remaining balance after insurance pays. Please complete and sign the following: Credit Card Authorization Initials Initials Initials I authorize North Dallas Dermatology Associates to bill my insurance for the services rendered today. Upon receipt of payment from my insurance company, I authorize North Dallas Dermatology Associates to charge the below listed credit card in the amount of the remaining unpaid balance. I understand that cosmetic procedures are not billed to my insurance. Should there be a remaining balance on cosmetic services, I authorize North Dallas Dermatology Associates to charge the below listed credit card in the amount of the remaining unpaid balance. An will be sent to notify me of the additional charge to my credit card. Patient Name Patients of Birth Credit Card Billing Address: Address line 1 Address line 2 City, state, zip code Card holders address Best number to be reached Name as it appears on credit card last four numbers on credit card Credit card expiration date _ Credit card holder authorizing signature OFFICE USE ONLY: Employee initials: saved/ Sent to PAS:
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:
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
Please Complete All Fields. Patient Name: Date of Birth: Marital Status: Address: City: State: Zip: Street/Apt #/PO Box
PATIENT REGISTRATION Please Complete All Fields Date: Patient Name: Date of Birth: Marital Status: First Last Address: City: State: Zip: Street/Apt #/PO Box *Preferred Phone#: ( ) Home: ( ) Cell: ( ) Work:
Medical Information. Past Surgeries
Name: of birth: : Chief Complaint: (reason for your visit) Referred by: ( )*Physician ( ) Patient to Patient ( ) Family ( ) Insurance ( ) Internet ( ) Other: *If referred by physician please give name:
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
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
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
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:
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
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
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
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
New Patient Packet. Thank you for choosing Shasta Regional Medical Group. Our office looks forward to serving you.
New Patient Packet Thank you for choosing Shasta Regional Medical Group. Our office looks forward to serving you. Prior to your appointment: Please complete the attached New Patient Paperwork. Be sure
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 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
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 /
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
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
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
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:
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
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
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
RESPONSIBLE PARTY (Complete only if patient is a minor or otherwise not financially responsible): Name: DOB: / / SSN: - -
Date / / Chart # PATIENT INFORMATION: Name: DOB: / / SSN: - - Address: Phone (H) ( ) - Gender: M F Phone (C) ( ) - Race: *OK to leave message with personal health information on voicemail of above phones:
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
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
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,
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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
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
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
RESPONSIBLE PARTY (Complete only if patient is a minor or otherwise not financially responsible): Address: DOB: / / SSN: - -
Date / / Chart # PATIENT INFORMATION: Name: DOB: / / SSN: - - Address: Phone (H) ( ) - Gender: M F Phone (C) ( ) - Race: *OK to leave message with personal health information on voicemail of above phones:
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)
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
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
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,
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
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?
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
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.:
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:
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
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
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.
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
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 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
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):
Gary W. White, M.D. Dean A. Cione, M.D. Jeremy S. Carrasco, M.D. Ramsey A. Stone, M.D
PATIENT REGISTRATION FORM First Name: MI: Last Name: Date of Birth: Address: Apt#: City: State: Zip: Home Phone: ( ) Cell Phone: ( ) Work Phone ( ) SS#: - - SEX: Female Male E-mail Address: Ethnicity:
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:
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
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
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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 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
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
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
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
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
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
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
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 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
Chong S Kim, MD ENT and Facial Plastic Surgeon
Chong S Kim, MD ENT and Facial Plastic Surgeon 100 Commons Way, Suite 701 300 Perrine Rd., Suite 301 Holmdel, NJ 07733 Old Bridge, N.J 08857 Phone: 732-796-0182 Phone: 732-727-1355 Fax: 732-796-0186 Fax:
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
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:
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
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
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
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 REGISTRATION
PATIENT REGISTRATION Today s Date Last Name First Name Address City, State, Zip Email Address Home Phone Work Phone Cell Phone SS# Date of Birth Age Sex ( ) Male ( ) Female Marital Status (check one):
PATIENT QUESTIONNAIRE DATE OF VISIT: Pg. 1
PATIENT QUESTIONNAIRE DATE OF VISIT: Pg. 1 PATIENT NAME DATE OF BIRTH AGE PLEASE PROVIDE THE FOLLOWING MEDICAL INFORMATION TO THE BEST OF YOUR ABILITY: What problems are you here for today? List any allergies
PATIENT INFORMATION. Last Name: First Name: Middle Initial: Address:
PATIENT INFORMATION Today s Date: Last Name: First Name: Middle Initial: Address: STREET CITY STATE ZIP CODE Gender: Male Female Social Security #: Date of Birth: Home Phone: Cell Phone Work Phone: E-mail:
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
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
EAR, NOSE, AND THROAT ASSOCIATES, PC Financial Policy Effective September 1, 2014
EAR, NOSE, AND THROAT ASSOCIATES, PC Financial Policy Effective September 1, 2014 Patient name: Account# Ear, Nose and Throat Associates, PC, believes that in the interest of good health care practices,
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
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:
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 REGISTRATION FORM CAROLINA EAR, NOSE & THROAT
PATIENT REGISTRATION FORM CAROLINA EAR, NOSE & THROAT Last Name: First: M.I.: Sex: Age: Date of Birth / / Social Security # - - Race: Ethnicity: Language Spoken: If patient is child / under 18: Parent
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
PATIENT INFORMATION NOTICE OF PRIVACY POLICY PATIENT ACKNOWLEDGEMENT
PATIENT INFORMATION ( MR / MRS / MS / DR ) FIRST MIDDLE LAST DATE OF BIRTH AGE MARITAL STATUS (circle one) Married / Divorced / Single / Widowed STREET ADDRESS APT/LOT/ROOM/SUITE CITY STATE ZIP GENDER
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
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:
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
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
Jandali Plastic Surgery
Jandali Plastic Surgery PATIENT INFORMATION FORM : FirstMiddle Last Address: City State Zip Code Home Phone #( ) - Work #( ) - Cell #( ) - Emergency # ( ) - Emergency Contact Social Security Number - -
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,
Address. City/State/Zip. Marital Status: S M D W Sex: M F Date of Birth / / Age. Primary Phone Secondary Phone. Employer PARENT/GUARDIAN
PATIENT INFORMATION First Name M.I Last Name Address City/State/Zip SSN.#_ Marital Status: S M D W Sex: M F of Birth / / Age Primary Phone Secondary Phone Employer Email PARENT/GUARDIAN Name of Birth /
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
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
PAYMENT POLICY: Payment or partial payment is required on the day of visit.
Patient Information Date Patient Name (First) (M.I.) (Last) Date of Birth SSN Gender Male Female Transgender-Male Transgender-Female Marital Status Race Ethnicity Preferred Language Patient Address City
Patient Information Form
ALASKA DIGESTIVE AND LIVER DISEASE, LLC Ronald J Boisen, M.D. Daryl M. McClendon, M.D. Jeffrey W. Molloy, M.D. Patient Information Form Patient s Name: Age: DOB: Sex: Male Female Marital Status: S M W
Street Address Apt. No. City State Zip. Race: Ethnicity: Hispanic Not Hispanic or Latino. Marital Status: Single Married Widowed Divorced
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:
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 FORMS
PATIENT REGISTRATION FORMS Last Name: First Name: Middle Initial: DOB: / / Street Address: City: State: Zip: Primary Phone: - - Secondary Phone: - - SSN: - - Sex: M / F Email: (for patient portal purposes
(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.
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
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