Last Name: First Name: M / F Today s Date: Birthdate: Age: Height: Weight:
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1 NEW PATIENT HISTOR Last Name: First Name: M / F Today s Date: Birthdate: Age: Height: Weight: How did you hear about us? Insurance Physician Friend Other Primary care physician: Name City Phone Referring physician: Name City Phone Preferred pharmacy: Name City Phone We wish to address all of your medical, surgical and cosmetic dermatology concerns. Completing the table below begins a record of priorities you wish us to devote attention to now and in the future. Due to new restrictions in many insurance plans, a limited number of items can be evaluated or performed during a visit. For this reason, after a full assessment of your concerns today, you and the physician may re-prioritize your list to address the items of upmost medical necessity or well-being first. We look forward to working with you to successfully address all of your dermatologic needs. LIST OF DERMATOLOGIC CONCERNS OU WANT TO ADDRESS List your concerns first and then determine the priority on the far right hand column. Concern / Body Location When did you first notice it? Does anything make it better? Does anything make it worse? Mild, moderate or severe? Signs & symptoms (i.e. itch, burn, sting, none) What treatments, if any, have you tried? Priority (1-3) A / B /
2 HAS A PHSICIAN OFFICIALL DIAGNOSED OU WITH AN OF THE FOLLOWING? (Circle es if positive) Abnormal healing scars (Keloids) Hives OUR SURGICAL HISTOR Antibiotics before surgery Hyperhidrosis (excessive sweat) Artificial heart valves Anxiety Hyperthyroidism Defibrillator / Pacemaker Arthritis Hypothyroidism Hysterectomy (date) Bleeding problems Kidney Disease Implants Blistering Skin Condition Patch Testing Joint replacement Blood clots (DVT) (date) Psoriasis Radiation treatment Dialysis Spider Veins Transplant (date) Eczema (Atopic Dermatitis) Stroke Other Fibromyalgia Tuberculosis Hay Fever / Allergies Ulcerative Colitis Heart Disease (CHF, etc) Varicose Veins Hepatitis, Type Herpes - genital or mouth (circle) FOR FEMALES ONL: FOR MALES ONL: High blood pressure Currently Breast Feeding Prostate Cancer High cholesterol Pregnant (due date) Benign Prostatic Hypertrophy HIV / AIDS Irregular menses/menopause Prostate Cancer Updated
3 OUR Skin Cancer History (Actinic Keratosis, Basal Cell, Squamous Cell, Melanoma) Indicate type of growth (diagnosis) Location Treatment date Method of treatment DO OU HAVE A PARENT OR SIBLING WITH A HISTOR OF MELANOMA? (CIRCLE ONE) ES NO Parent: Sibling: OUR SOCIAL HISTOR N Religious preference? N Hobbies N Smoke tobacco - cigarettes, cigars or pipe (indicate by circling) N Smoke tobacco - / day for years ear quit N Chew tobacco - # of cans / day # of years ear quit N If you don t smoke, does someone smoke in your home? N Have you ever had a blistering sunburn? N Sun exposure rarely occasionally frequently N Do you wear a daily sunscreen? brand N Have you ever used a tanning bed? If yes, how often have you used a tanning bed? (# of total sessions) If yes, when did you start using a tanning bed? (age) Updated
4 OUR COSMETIC HISTOR N Blepharoplasty (Eyelid lift) N IPL (laser for red, brown spots) N Botox, Dysport (Wrinkles of the face) N Fillers - Juvederm, Restylane, other N Chemical peel N Latisse (Eyelash treatment) N Face lift N Microdermabrasion N Fractional Laser (Laser skin rejuvenation) N Sclerotherapy N Hyperhidrosis Treatments N Other: OUR MEDICATIONS & ALLERGIES CIRCLE if you take any of the following: aspirin vitamin E St. johns wart garlic fish oil DERMATOLOG MEDICATION DIRECTIONS FOR USE START END REASON FOR CHANGE OR DISCONTINUATION OTHER MEDICATIONS DIRECTIONS FOR USE START END CONDITION Updated
5 HERBAL, SUPPLEMENTAL & NON-PRESCRIPTION MEDICATIONS DIRECTIONS FOR USE START END DIAGNOSTIC USE NO ALLERGIES ALLERGIES:,, Adhesive Latex If you need additional space, let us know and we will provide an additional sheet. Updated
6 Practice Policies Our goal is to provide quality medical care in a timely manner. In order to do so, we have had to implement a cancellation and no-show policy. The policy enables us to better utilize available appointments for our patients in need of medical care. Initials Cancellation of an Appointment In order to be respectful of other patients needs, please be courteous and call our office promptly if you are unable to attend an appointment. This time will be relocated to someone who is in urgent need of treatment. We ask that you make an attempt to call hours in advance. No Show Policy A no show is a missed appointment that was not canceled in advance with at least a 24 hour notice. No shows inconvenience other patients who need access to medical care. Two no-show appointments in a six-month period will result in dismissal from the practice. New patients who do not show for their appointment may not be rescheduled. Late Arrivals In an effort to serve our patients in a more timely manner, we request that you be on time for your scheduled appointment. In the event you are running late, please be respectful and call ahead. If you are late for your appointment, you may be asked to reschedule. Walk-In Patients We realize that health conditions often occur unexpectedly. Walk-in care may be provided for urgent dermatologic care. We will do our best to accommodate you at the earliest possible time. Please consider that you may have to wait for an extensive amount of time, as we see other patients as scheduled. We suggest ahead to find out if there is a time we would most likely be able to accommodate you. If the need is not urgent, you will be asked to schedule an appointment. In the case of a walk-in, the provider will address the presenting problem only. Insurance Filing and the Law Most of the services provided in this office are medically necessary and paid for by your insurance company. Unfortunately, not all services are covered and may be considered elective or cosmetic. In cases where the service has been denied by your insurance, you will be personally responsible for the bill. Federal laws addressing insurance company transactions require that we submit claims to insurance company accurately, reporting the exact services performed and the exact reason for performing them. We are not allowed to alter the medical records or claims forms. Our practice strictly adheres to these laws, and will submit claims to all insurance companies in this manner. Secondary Insurance Updated
7 Our corporate billing office will file secondary insurance for our patients once, as a courtesy. After 90 days, if your secondary insurance has not paid on a claim, the balance will become patient responsibility. Non-Covered Services Are our Responsibility. Medical plans have many unique stipulations. If you are not sure if a service is covered by your plan, you will need to call your insurance company in advance to see what your financial responsibility will be prior to being seen and treated. It is the patient s responsibility to obtain a referral for HMO plans. If you fail to obtain a referral, you will be financially responsible for all charges. Understanding our Financial Obligation As a patient, it is in your best interest to know if your plan is contracted with Jonathan Richey, DO and to understand your insurance plan benefits. This includes, but not limited to, understanding your responsibility for any deductibles, co-insurance, or co-payment amounts prior to any visit. ou may have different deductibles, co-insurance, or co-payment amounts, depending on the contracted status of your insurance company. Patients are responsible for all payments including, but not limited to co-pays, co-insurance, deductibles, and past due balances at the time of service. If your account is past due, it will be turned over to our collection agency. We accept cash, check, debit cards, MasterCard, Visa, American Express, and Money Orders. Pathology ou may receive a separate bill for laboratory or pathology services from an off-site lab for any tests your physician orders. Or you may receive a separate pathology bill from Dr. Richey, as he is also a dermatopathologist and my read your pathology slides himself. In the case you receive a bill from an outside lab; you may discuss any bills with that lab. It is also important to understand your insurance plan s current benefit and coverage rules. Policies and coverage determinations may vary from year to year. Please be aware that most procedures performed in our office are considered surgical, according to the American Medical Association. This includes excisions, shaves, biopsies, intralesional injections, and destructions by any method. Any method includes electrosurgery, cryosurgery, laser and chemical treatment of a lesion. Lesions include molluscum, warts, milia, benign, premalignant, or malignant lesions. Surgeries are often applied toward patient s deductibles and/or co-insurance. Not all services are covered in all insurance contracts. If your insurance plan benefits do not cover a service or procedure, you will be held personally responsible for payment of these charges. To find out what your insurance plan benefit covers and what your financial obligation may be, call the customer service or member services department of your insurance company (the phone numbers are on your insurance card). our employer s human resources department may also be a source for information and assistance. Updated
8 Consent for Photography Patient Name: Date: I consent for medical photographs to be made of me or my child (or for person whom I am legal guardian). I understand that the information may be used in my medical record, for purposes of medical teaching at Baylor Scott and White Dermatology Specialists, or for publication in medical textbooks or journals as I have designated below. By consenting to these medical photographs I understand that I will not receive payment from any party. Refusal to consent to photographs will in no way affect the medical care I will receive. If I have any questions or wish to withdraw my consent in the future I may contact the staff at Baylor Scott and White Dermatology Specialists at (469) By signing this form below, I confirm that this consent form has been explained to me in terms which I understand. Please sign one of the following: 1. I consent for these photographs to be used in medical publications, including medical journals, textbooks, and electronic publications. I understand that the image may be seen by members of the general public, in addition to scientists and medical researchers that regularly use these publications in their professional education. Although these photographs will be used without identifying information such as my name, I understand that it is possible that someone may recognize me. I also agree for my image to be shown for teaching purposes at Baylor Scott and White Dermatology Specialists and to be used in my medical record. Patient Signature Date For Teaching Purposes ONL: 2. I agree for my image to be shown for teaching purposes AND to be used for my medical record but NOT FOR medical publication. Patient Signature Date Updated
Last Name: First Name: M / F Today s Date: Birthdate: Age: Height: Weight:
NEW PATIENT HISTORY Last Name: First Name: M / F Today s Date: Birthdate: Age: Height: Weight: How did you hear about us? Insurance physician friend other Primary care physician: Name City Phone Referring
6140 W. Atlantic Avenue * Delray Beach, FL Tel: (561) * (888) 357-DERM * Fax: (561)
Today s Date: Reason for Visit: Patient Name: (Last) (First) (Middle) Permanent Address (Local): Street City/State/Zip: Secondary (Out of State) Address: City/State/Zip: Pharmacy Phone: City: Cross Streets:
Patient Information *Please Complete All Sections*
Front Desk Check-In Initials Patient Information *Please Complete All Sections* Account # (Office Use Only) Name (First, MI, Last) Date of Birth / / Age: Sex: M F Mailing Address Apt # City State Zip Home
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
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
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
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 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 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
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. 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 FORM. Address. Street# Street Name Apt.# City State Zip Code. Employer: Date of Birth: / / Age Month Day Year
PATIENT REGISTRATION FORM Name: Jr. Sr. First Middle Last Prefer to be called: Gender(Sex): M F Married Divorced Single Widowed Race : White Black Asian Indian Other Declined to Provide Ethnicity: Hispanic
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 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
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
Dermatology Associates of Indy
PATIENT INFO IF REFERRED BY PHYSICIAN GIVE DOCTOR S NAME AND PHONE #: FIRST NAME: LAST NAME: ADDRESS LINE 1: TODAY S DATE: ADDRESS LINE 2: CITY: STATE: ZIP CODE: PRIMARY PHONE #: GENDER: MALE FEMALE CELL
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)
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:
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
Cosmetic Medical History
Cosmetic Medical History How did you hear about us? Name Date of Birth / / Today s Date / / Reason for today s visit: Please circle your cosmetic concerns: Sun spots / Age Spots Wrinkles Birthmarks- Brown/Red
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
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 Registration Form Please present insurance cards and photo ID to the receptionist so copies may be made.
Patient Registration Form Please present insurance cards and photo ID to the receptionist so copies may be made. Name: Jr. Sr. Last First Middle Prefer to be called: Married Single Date of Birth / / Patient
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
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. 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
Cosmetic Medical History
Cosmetic Medical History How did you hear about us? Name Date of Birth / / Today s Date / / Reason for today s visit: Please circle your cosmetic concerns: Sun spots / Age Spots Wrinkles Birthmarks- Brown/Red
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
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:
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:
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 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
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
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 /
Name: LAST FIRST MIDDLE INITIAL. Address: City: State: Zip: SSN: DOB: Age: Home Phone: Work Phone: Cell Phone: Occupation:
Today s Date: Name: LAST FIRST MIDDLE INITIAL City: State: Zip: SSN: DOB: Age: Home Phone: Work Phone: Cell Phone: Occupation: Mailing Address (if different): City: State: Zip: Primary Care Physician:
GARRAMONE PLASTIC SURGERY (239)
Information as of (enter today s date) (Please Print Legibly & Fill In or Correct All Fields) s Name Address First Middle Last Street & Apt # City State Zip Home Phone Cell Phone Other Phone Any restrictions
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
Amy Wechsler, MD. Dermatology. Welcome To Our Office!
Welcome To Our Office! 1. Your appointment time is reserved for you. If you must reschedule an appointment, please try to do so in a timely fashion so that another patient may be accommodated and you can
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
Dear Patient: Welcome and thank you for choosing our practice.
Dear Patient: Welcome and thank you for choosing our practice. Please bring the following with you to your appointment: Your completed forms, along with your current insurance card, photo identification
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: 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
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
Welcome to Pacific Coast Dermatology. It is our pleasure to serve you in a setting staffed
Dr. T. Anthony Hoang-Xuan, FAAD Board-Certified Dermatologist Medical Surgical Cosmetic Laser Welcome to Pacific Coast Dermatology. It is our pleasure to serve you in a setting staffed with the leading
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
Dear Patient: Welcome and thank you for choosing our practice.
Dear Patient: Welcome and thank you for choosing our practice. Please bring the following with you to your appointment: Your completed forms, along with your current insurance card, photo identification
Thomas Dermatology General and Pediatric Dermatology MOHS Surgery and Cosmetic Dermatology
To Our Valued Patients: Thomas Dermatology We apologize in advance for the increased paper work, specifically the bubble sheets, you are required to fill out. As mandated by the Federal Government, we
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
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
Dear Patient: Welcome and thank you for choosing our practice.
Dear Patient: Welcome and thank you for choosing our practice. Please bring the following with you to your appointment: Your completed forms, along with your current insurance card, photo identification
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?
WARTHAN DERMATOLOGY CENTER
Mandy L. Warthan, M.D. WARTHAN DERMATOLOGY CENTER Robert Marinaro, M.D. 5971 Virginia Parkway, Suite 100 5913 Virginia Parkway, Suite 300 McKinney, Texas 75071 McKinney, Texas 75071 Phone 972-542-4646
Patient Registration Form
Patient Registration Form Please bring insurance card and photo ID to your appointment Patient Name of Birth Today s Address City State Zip Home Phone Cell # Work # Circle your contact preference: Home
PLEASE. To make your check-in process as smooth and fast as possible: DO NOT DATE THE FORMS BEFORE ARRIVING TO THE OFFICE
PLEASE To make your check-in process as smooth and fast as possible: WRITE LEGIBLY (PRINT) FILL ALL FORMS COMPLETELY DO NOT DATE THE FORMS BEFORE ARRIVING TO THE OFFICE BECAUSE WE WILL SCAN THESE FORMS
WHITE ROCK DERMATOLOGY Garland Road, Suite 210; Dallas, TX Tel:
10611 Garland Road, Suite 210; Dallas, TX 75218 Tel: 214-324-2881 Patient s Full Name: Gender: Age: Marital Status: Single Married Widowed Divorced DOB: Social Security Number: Occupation: Address: Apt
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
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:
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?
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
NOTICE ABOUT REFRACTION
NOTICE ABOUT REFRACTION We have you scheduled for a Complete Eye Exam or surgical consultation today. If you are here for your Eye examination and you are experiencing blurry vision or any visual changes,
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
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
NOTICE ABOUT REFRACTION
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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. (Please complete all sections) NAME OF PARENT(S) OR GUARDIAN(S): PARENT, SPOUSE, OR RESPONSIBLE PARTY If Different from Patient
Date: PATIENT INFORMATION (Please complete all sections) Office Location: PATIENT NAME (Last, First M.I.): DATE OF BIRTH: / / NAME OF PARENT(S) OR GUARDIAN(S): SSN#: SEX: (_) Male (_) Female MARITAL STATUS:
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
List all medications you are currently taking (including prescriptions, over-the-counter, & vitamins)
10680 Medlock Bridge Rd., Suite 204 Johns Creek, GA 30097 Ph 470.282.5729 Fax 770.674.5795 Dr. Paola Bonaccorsi Dr. Dale Sarradet Patient name: Date of Birth: / / Today's Date: / / Reason for today's visit:
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 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 /
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:
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
PATIENT REGISTRATION
16611 S. 40 th Street, Suite 100, Phoenix, Arizona 85048 480.610.6366 www.stocktondermatology.com PATIENT REGISTRATION Date: Please circle: NEW or UPDATED **Please PRINT and COMPLETE using BLACK INK only**
Who to call for an emergency: Name: Relationship: Home Phone: ( ) - Work Phone: ( ) - Cell Phone: ( ) -
4425 Ponce de Leon Blvd., Suite 115 Email:info@ Dr. Mercedes Gonzalez, Pediatric Dermatologist Patient Information: Patient Name: Social Security Number: / / Date of Birth: / / Sex: M / F (Circle one)
1. Please bring a Hard Copy of your Current Active Insurance Card, Referral and Photo ID with you.
Welcome to Abeles Dermatology Aesthetic & Laser Arts. We are pleased to be able to help you with all of your Medical and Cosmetic Dermatology needs. Please take a few moments to read this page. Please
LUPTON DERMATOLOGY MR# Today s Date:
LUPTON DERMATOLOGY MR# Today s Date: Prefix Mr. Mrs. Miss Ms. Dr. Preferred Name: Patient s Name: First Middle Last Address: Street & Apt # City State Zip SS#: Birthdate Age: Sex: Female Male Marital Status:
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:
California Vein Specialists
Name: Birthdate: Address: City: State: Zip: Home Phone: ( ) Okay to leave message with details Do not leave detailed message Cell Phone: ( ) Okay to leave message with details Do not leave detailed message
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
Past Medical & Surgical History (Please list any diseases or conditions that you have now or have ever had) (DO NOT LEAVE BLANK)
Date of visit: Name: SS#: - - DOB: / / Race: Ethnicity: Language: Reason for your visit today: Referring physician: PCP: Best number to reach you for your test results: May we leave a message? Yes No Male
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
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,
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
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
The Dermatology Center at Ladera Financial and Care Consent Agreement
The Dermatology Center at Ladera Financial and Care Consent Agreement Patient Information: / / Patient Name (first, middle initial, last) Date of Birth: month day year Patient s Insurance Information:
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
PLEASE PRINT CLEARLY
PATIENT INFORMATION FORM Rev. 02/2018 PLEASE PRINT CLEARLY New Patient Name Change Address Change Insurance Policy/Holder Change PATIENT INFORMATION Last Name: _ First Name: Middle Initial: DOB: Sex: Male
COSMETIC HISTORY FORM
COSMETIC HISTORY FORM IF THIS IS YOUR FIRST VISIT WITH US, PLEASE TAKE THE TIME TO FILL THIS FORM OUT COMPLETELY. Patient Name: Age: Date of Birth: Weight: Height: Address: City: State: Zip: Home Phone:
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
Advanced Dermatology and Skin Cancer Specialists
PATIENT INFORMATION (Please complete all sections) Date: Office Location: NAME(Last,First M.I.): DATE OF BIRTH: / / NAME OF PARENT(S) OR GARDIAN(S): SSN#: SEX: (_)Male (_)Female MARITAL STATUS: (_)Single
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.:
Patient Registration Form. Date of Birth: Marital Status: Social Security Number:
2800 E Broad Street, Suite 124 Mansfield, TX 76063 P: 817-539-0959 F: 817-539-0480 723 N Fielder Road, Suite C Arlington, TX 76012 P: 817-539-0959 F: 817-261-1123 780-B NE Alsbury Blvd Burleson, TX 76028
Dermatology and Cutaneous Surgery
Dermatology and Cutaneous Surgery Dermatology Name Date / / Medical Ethnicity DOB / / History Primary Doctor/Clinic Referred by your doctor? Yes / No Reason for today s visit Do you have cosmetic concerns?
**The Dermatology Clinic sends all appointment reminders via text**
PATIENT INITIAL EVALUATION INFORMATION (Adult) DATE Patient Name Date of Birth / / First Middle Last Month Day Year Mailing Address Street City State Zip Home Phone Work Phone Cell Phone **The Dermatology
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
Candace L. Peterson, DMD
Candace L. Peterson, DMD PATIENT REGISTRATION Date A. Responsible Party SS # - - Last First Middle Home Address Birthdate E-mail City State Zip Code Home Phone ( ) - Cell Phone ( ) - Work Phone ( ) - Employer
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