New Patient Registration
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- Homer Lindsey
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1 New Patient Registration Today s Date: 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 Marital Status Single Married Widowed Divorced Other Ethnicity Hispanic or Latino Not of Hispanic or Latino Unknown Race American Indian or Alaska Native Asian Black or African American Native Hawaiian White Other Primary Care Dr. Primary Care Dr. Phone # Pharmacy Name Pharmacy Phone # Insurance Information Primary Insurance Referral required? No Ye s ID# Policyholder Name Group# Date of Birth Secondary Insurance ID# Policyholder Name Group# Date of Birth 1 SunWise Dermatology & Surgery, LLC 102 Sleepy Hollow Dr. Suite No. 203, Middletown DE (302)
2 Guarantor Information ( Required - fill this box if the patient is a minor ) First Name Date of Birth MI Last Name SSN Phone Employer Work Cell I consent to be treated by Dr. Jennifer LaRusso DO & other healthcare practitioners providing service at SunWise Dermatology & Surgery. I understand that I am responsible for and any all charges (or amounts based on payment arrangements agreed to by them) that are included during my treatment and not paid or otherwise satisfied by my insurance benefits or other third party benefits. Where Medicare benefits are applicable, I certify that the information given by me in applying for payment under Title VIII of the Social Security Act is correct. I assign and request payment of authorized Medicare benefits to SUNWISE DERMATOLOGY & SURGERY, LLC. I authorize any holder of medical or other information about me to release to Medicare and its agents any information needed to determine the benefits of related services. I consent to the use and disclosure of my health information for treatment, payment & healthcare operations purposes as described in SunWise Dermatology & Surgery Notice of Privacy Practices. Signature Date
3 History & Intake Form Please Check All That Apply Patient Name: Past Medical History Past Surgical History Anxiety Arthritis Asthma Atrial Fibrillation Bone Marrow Transplant BPH Breast Cancer Colon Cancer COPD Coronary Artery Disease Depression Diabetes End Stage Renal Disease GERD Hearing Loss Hepatitis Hypertension HIV / AIDS Hypercholesterolemia Hyperthyroidism Hypothyroidism Leukemia Lung Cancer Lyphoma Prostate Cancer Radiation Treatment Seizure Stroke NONE Other Appendix (Appendectomy) Bladder (Cystectomy) Breast: Breast Biopsy Breast:Lumpectomy (Right, Left, Both) Breast:Mastectomy (Right, Left, Both) Colon (Colectomy) Colon Cancer Resection Colon (Colectomy) Diverticulitis Colon: Inflammatory Bowel Disease Colon: Colostomy Gallbladder (Cholecystectomy) Heart: Coronary Artery Bypass Surgery Heart: Heart Transplant Heart: Mechanical Valve Replacement Heart: PTCA Joint Replacement: Hip (Right, Left, Both) Joint Replacement: Knee (Right, Left, Both) Kidney: Kidney Biopsy Kidney: Kidney Stone Removal Kidney: Kidney Transplant Liver: Hepatectomy Liver: Liver Transplant Liver: Shunt Ovaries (Oophorectomy) Endometriosis Ovaries (Oophorectomy) Ovarian Cancer Ovaries: Tubal Ligation Prostate: Prostate Biopsy Prostate: Prostate Cancer Prostate: TURP Rectum: APR Skin: Basal Cell Carcinoma Skin: Squamous Cell Carcinoma Skin: Melanoma Skin: Skin Biopsy Testicles (Orchiectomy) Uterus: Fibroids Uterus: Uterine Cancer Uterus: Cervical Cancer NONE Other SunWise Dermatology & Surgery, LLC 102 Sleepy Hollow Dr. Suite No. 203, Middletown DE (302)
4 Skin Disease History Acne Actinic Keratoses Basal Cell Carcinoma Blistering sunburns Dry Skin Eczema Flaking or Itching Scalp Hay Fever / Allergies Melanoma Poison Ivy Precancerous Moles Psoriasis Squamous Cell Skin Cancer NONE Other Do you wear sunscreen? Yes No Do you tan in a tanning salon? Yes No If yes, what SPF? Family history of Melanoma? Yes No Alerts HIV Positive Latex Allergy Pregnant or planning a pregnancy Breastfeeding Become faint or dizzy with surgical procedures Blood Thinners Pacemaker Defibrillator History of MRSA Allergic to sulfa drugs or creams Allergies to adhesives Allergies to topical antibiotics Rapid heartbeat with Epinephrine Allergy to Lidocaine Yeast infections with antibiotics GI upset with antibiotics Active / History of Hepatitis West Africa: Travel or contact NONE Medications : List all current medications Allergies : List all allergies and reactions if known Smoking Status Daily Smoker Someday Smoker Former Smoker Never Smoker Unknown Start Smoking (year) Quit Smoking (year) Alcohol Intake None 1 or less per day 1-2 per day 3 or more per day Driving Status Daytime Nighttime Exercise Frequency Unspecified Several times daily Once a day A few times a week A few times a month Never Other Caffeine Use Unspecified Several times daily Once a day A few times a week A few times a month Never Other SunWise Dermatology & Surgery, LLC 102 Sleepy Hollow Dr. Suite No. 203, Middletown DE (302)
5 102 Sleepy Hollow Drive, St. 203 Middletown, De Patient Name (Print) DOB Legal Guardian Name Authorizations I authorize the release of information necessary to process this claim and also authorize payment of medical benefits directly to SunWise Dermatology & Surgery, LLC. I certify that the information I furnish is true and correct. In order to establish optimal relations with our patients and to avoid misunderstanding regarding our payment policies, our staff is trained to inform you of the financial payment policies of this office. Payment is required for services at the time they are rendered. We accept payment in form of cash, check, Visa, MasterCard, Discover, or American Express. In the event of hospitalization or major procedures, our office will file with the appropriate insurance. However, before such claims are filed, coverage will be pre-verified and you will be asked to pay any unmet deductible, non-covered services and copayments. Interest payments may be assessed for failure to pay bills within a reasonable time frame. Your signature below communicates your understanding and willingness to comply with this policy. Patient or Legal Guardian Signature Today s Date Medicare Health Insurance Form I request that payment of authorized Medicare benefits be made either to me or my behalf to SunWise Dermatology & Surgery, LLC for any services furnished to me by SunWise Dermatology & Surgery, LLC. I authorize any holder of medical information about me to be released to the Health Care Financing Administration and its agents any information needed to determine these benefits payable for related services. Patient or Legal Guardian Signature Today s Date Medical information may be released to Relationship Phone
6 Cancellation Policy We at SunWise Dermatology & Surgery, are committed to meeting our patient s health care needs. Your appointment is time set aside specifically for you. When you miss, cancel or reschedule your appointment it prevents us from being able to help another patient. We understand that in some cases it may be difficult to keep an appointment and we will waive the fee for the first occurrence. Insurance does not cover missed appointments. Please provide us 24 hours notice if you wish to cancel or reschedule a non-surgical appointment. If you fail to show up; or fail to notify us 24 hours before your non-surgical appointment, you will be charged a $25.00 fee. Please provide us 48 hours notice if you wish to cancel or reschedule a surgical (Mohs/excision) appointment. If you fail to show up; or fail to notify us 48 hours before your surgical (Mohs/excision) appointment, you will be charged a $50.00 fee. I have reviewed this document and understand that I will be financially responsibility for ALL missed, canceled or rescheduled appointments if I do not give sufficient notice as stated above. Patient Signature Date ************************************************************************************************** For Office Use Only: Date POA received: Employee Initials: Filed in patient s chart: Yes NO SunWise Dermatology & Surgery Employee Initials / Date: SunWise Dermatology & Surgery, LLC 102 Sleepy Hollow Dr. Suite No. 203, Middletown DE (302)
7 Consent to Treat a Minor Today s Date: Patient Name: Date of Birth: Address: _ Responsible Party s Name: Phone: Emergency Contact: Phone: The undersigned hereby requests and authorizes SunWise Dermatology & Surgery, LLC. to perform tests, procedures and render treatment to, a minor. Patient Name This authorization extends to all SunWise Dermatology & Surgery, LLC offices, doctors, physician assistants, and office staff members. As of the date below, the undersigned states and avows to have the legal right to select and authorize health care services for the minor named above. If applicable, under the terms and conditions of divorce, separation or other legal authorization, the consent of a spouse, former spouse, or other parent is not required. If authority to select and authorize the care should be revoked or modified in any way, the undersigned does hereby agree to notify SunWise Dermatology & Surgery, LLC as soon as possible. Signature of Person Authorized to Sign for Patient Date Printed Name Relationship to Patient Witness SunWise Dermatology & Surgery, LLC 102 Sleepy Hollow Dr. Suite No. 203, Middletown DE (302)
8 102 Sleepy Hollow Drive, Ste. 203 Middletown, DE HIPPA Notice of Privacy Practices We are required by law to maintain the privacy of, and provide individuals with this notice of our legal obligations and private practices with respect to protected health information. If you have any objections to this form, please ask to speak with our HIPPA Compliance Office in person or at the above listed number. If you have biopsy, culture or an excision done, your information will be sent to be following facilities: Green Clinics Laboratory, Miraca, LabCorp/Dianon or Quest. Your signature below is an acknowledgement that you have received this Notice of Privacy Practices. If you are signing as the patient s Power of Attorney (POA), you MUST provide a copy of the Power of Attorney document to our office upon completion of signing this document and/or any other documents completed in our office. Otherwise, the patient MUST sign all forms in order to be treated in our facility. Patient Name: Signature: Date: If patient is a minor or if you are signing as the patient s Power of Attorney (POA): Print Name: Relationship:
9 102 Sleepy Hollow Drive,Ste. 203 Middletown, DE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPPA) PATIENT PRIVACY AND RIGHTS DISCLOSURE SunWise Family Dermatology & Surgery and its employees disclose information given to us by you, your insurance company, primary care doctor and/or other medical professionals strictly for the purpose of treatment, payment of services rendered or health care operations. We do not sell mailing lists or disclose personal information about our patients except that which is needed to carry out our objectives, which is your health. In compliance with HIPAA guidelines, the patient understands that they have the right to review any information which is documented in the patient s record by our office and right to add an addendum to such records if recorded information is disputed. By signing this consent, you agree to allow SunWise Family Dermatology & Surgery to use and disclose personal information about you for the reason above. You have the right to revoke this consent at anytime but must be aware that we cannot guarantee your care unless we can communicate with other health professionals when necessary. This notice of privacy will become a part of the patient s medical record. Patient Signature Date
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103 W. South St. Woodstock, VA. 22664 Winchester, VA. 22602 (540) 409-5254 Office * (540) 409-5253 Fax Financial Policy We make every effort to provide prompt medical care to each of our patients. Effective
Welcome to Advanced Dermatology
Patients Name Welcome to Advanced Dermatology (First) (Middle) (Last) Today's Date Date of Birth Gender SS# Patient Employer Name City State Phone ( ) Phone ( ) E-Mail Financial Responsible party (Minors
PATIENT 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:
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
Thank you for choosing our practice. Please download all of the attached forms, complete and bring them with you to your appointment.
re' ILLINOIS DERMATOLOGY ID INSTITUTE Dear New Patient, Thank you for choosing our practice. Please download all of the attached forms, complete and bring them with you to your appointment. Please bring
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):
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
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
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
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
(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.
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
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
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
We look forward to meeting you soon!
Welcome to Carolina Glaucoma, We look forward to having you as a patient and assisting you in every way we can with your glaucoma needs. Here are some things to remember to make your first visit a successful
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:
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
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:
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
2800 Ross Clark Circle, Suite 2 Dothan, AL
2800 Ross Clark Circle, Suite 2 Dothan, AL 36301 334-677-1690 Minor Patient Registration Form First Name M.I. Last Name Preferred Name: Street Address: Apt, Lot, Suite # City: State: Zip: DOB: Age: Sex:
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/
Acknowledgement of Receipt of Notice of Privacy Practices. Benefits to Physician. Release of Information
PATIENT REGISTRATION : Patient Name: of Birth: Marital Status: Last, First Address: City: State: Zip: Street/Apt #/PO Box Home #: Cell #: Work #: Email: Sex: F M SSN #: Referred by: *Physician Patient
Employer/Occupation Employer Phone Emergency Contact Relation Phone Referring/Family Physician Phone
PATIENT DATA Please fill out this form so that we will have enough information to effectively bill your insurance. (Only1 form is needed for each patient) Name Date of Birth Sex: F / M Address Phone #1