New Patient Registration Please Complete Entire Packet
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- Dwain Bryant
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1 New Patient Registration Please Complete Entire Packet LAST NAME FIRST NAME MIDDLE NAME SS# DATE OF BIRTH Marital Status Sex Address City/State Zip Home Phone E- Mail Address Primary Care Physician Referring Physician (If Applicable) Cell Phone OK TO CONTACT VIA ? Y N Work Phone Phone Phone Preferred Pharmacy and Address (Required) Please list the names of individuals who can receive your medical records (Please include relation to patient) Phone (Required) Phone How Did You Hear About McLean Dermatology Center? Please list your race. Check all that apply. White American Indian or Alaska Native Asian Black or African American Other Race Decline to specify Native Hawaiian or Other Pacific Islander Please list your preferred language Please list your ethnic group Hispanic or Latino Decline to specify Not Hispanic or Latino Primary Insurance Information (If you are the policy holder write SELF) Insurance Company Insurance ID Number Relationship to Policy Holder Last Name First Name Middle Name SS# DOB Sex Address City/State Zip Home Phone Cell Phone Work Phone Secondary Insurance Information Insurance Company/ Insurance ID Number Policyholder Name Policy Holder DOB Policy Holder Name/Relationship Relationship to Policy Holder 1
2 Have you had skin cancer? YES - - IF YES, PLEASE EXPLAIN BELOW NO, I HAVE NOT HAD SKIN CANCER Type of Skin Cancer Location Year Treatment Melanoma Squamous Cell Basal Cell Has anyone in your family had skin cancer? YES Please specify which type: Melanoma Squamous Cell Carcinoma Basal Cell Carcinoma NO family history of skin cancer Please specify which family member(s): Do you have any pre- existing health conditions? Please check all that apply to you. Anxiety Yeast Infections with Antibiotics Pacemaker Arthritis GI Upset with Antibiotics Defibrillator Asthma Problems with Bleeding Artificial Joints within Past 2 Years Atrial Fibrillation Problems with Scarring (Irregular heartbeat) (Hypertrophic or Keloid) Artificial Heart Valve Cancer Immunosuppression Premedication Prior to Procedures Depression Changing Mole Allergic to Latex Diabetes Rash Allergic to Adhesive End Stage Renal Disease Abdominal Pain Allergic to Lidocaine Hepatitis Bloody Stool Blood Thinners High Blood Pressure Bloody Urine Currently Pregnant HIV/AIDS Chest Pain Planning a Pregnancy High Cholesterol Cough Breastfeeding Hyperthyroidism Fever or Chills Rapid Heartbeat with Epinephrine Hypothyroidism Headaches Organ Transplant Hearing Loss Joint Aches Kidney Disease Seizures Muscle Weakness Liver Disease Tuberculosis Neck Stiffness Coronary Artery Disease Psoriasis Night Sweats Former Smoker Eczema Shortness of Breath Current Smoker Hay Fever/Allergies Sore Throat Alcohol Use Allergic to Topical Antibiotic Ointments Wheezing Recreational Drug Use Stroke Thyroid Problems Tanning Bed Use Unintentional Weight Loss Please list all other pre- existing health conditions and past surgeries: Please list ALL current medications, supplements, painkillers, vitamins, etc Please list any allergies to medications NO KNOWN DRUG ALLERGIES SENSITIVE TO LATEX SENSITIVE TO ADHESIVE Has anyone in your family had any of these conditions? Condition Diabetes Type I or II Thyroid Disease Family member(s) with condition Condition Hair Loss Cancer (specify type) Family member(s) with condition 2
3 Cosmetic Interests I would like to know more information about the following skincare products: Eye Creams Retinols Scar Creams Sunscreen Cleansers Moisturizers I would like to know more information about the following: Aging Skin Stubborn fat bulges Skincare Products Down Turned Mouth Crows Feet Loss of Facial Volume Sun Spots/Age spots (brown spots) Facial Lines and Wrinkles Uneven Texture Under Eye Circles Thinning Lips Acne Scarring Brown Spots on Face/Hands Facial veins Facial Redness I would like more information about the following cosmetic procedures: Botox Laser for facial redness (IPL) Coolsculpting (fat removal) Dysport Sclerotherapy (spider/varicose veins) Scar Revision Anti- Aging Lasers (fine lines/wrinkles) Excessive Sweating Treatments Latisse (eyelash/eyebrow growth) Fillers to soften facial/hand/neck lines Nutrition counseling for acne, hair loss, Kybella (injections for permanent (Restylane, Juvederm, Voluma, Radiesse, eczema, or psoriasis reduction of chin fat) Sculptra, Belotero) Below, please circle any areas of concern: Love Handles Muffin Top Stomach bulges Saddlebags Bra Fat Inner Thigh Fat Chin Fat ( Double Chin ) 3
4 Financial Agreement & Acknowledgement of Privacy Practices At McLean Dermatology and Skincare Center PLLC, we are committed to providing the best dermatologic care. Please note: This agreement must be signed in order to be seen by providers at McLean Dermatology and Skincare Center INSURANCE POLICIES A. We accept Carefirst BlueCross BlueShield, PPO plans by Anthem Blue Cross Blue Shield, Cigna, UnitedHealthcare, Coventry, and Medicare as in- network providers. B. We cannot guarantee that we accept your specific plan as an in- network provider; it is your responsibility to verify your insurance benefits and coverage prior to your visits. C. We will not submit claims to any other insurance company other than those listed above. If you have a secondary insurance in addition to one of the plans listed above, we will file a claim to your secondary insurance as an out- of- network provider. In such instances, we cannot guarantee complete coverage. D. If we do not accept your insurance, the charges for all services are due in full at the time of service. E. Insurance reimbursement is a contract between you and your insurance company. It is essential that you understand which services and procedures are covered by your insurance plan and obtain any necessary authorizations or referrals prior to your appointment with us. F. It is your responsibility as the patient to understand your insurance plan limits and restrictions that affect coverage of services you receive. G. If your insurance company requires you to use a specific laboratory in order for laboratory fees to be covered, it is your responsibility to notify us. OFFICE FEES AND PAYMENTS A. As the patient, it is your responsible for all co- payments, deductibles, and coinsurance amounts that are not covered by your insurance plan. If there is a balance due after insurance pays for your visit, payment for such amounts is your responsibility. B. Charges for all visits, treatments and procedures are due at the time of service. C. Medicare patients are responsible for any balances due for services that are not covered by Medicare. D. If you have any outstanding balances with our office, they must be paid in full before your next visit. E. We accept cash and all major credit cards. We do not accept checks. F. For NSF checks (checks returned for non- sufficient funds), a $50 NSF charge will be billed to your account. G. If proof of insurance is not provided at the time of service, you are responsible for the entire fee for the consultation and/or procedure at the time of service, and a $150 service fee for retroactively billing your insurance will be applied to your account. H. In the case of an account overpayment, the credit will remain on your account unless you request otherwise. 24- HOUR CANCELLATION POLICY A. You will be billed a $50 No Show/Cancellation Fee for each consultation cancelled within 24 hours of your scheduled appointment. B. You will be billed a $150 No Show Fee/Cancellation for all procedure appointments cancelled within 24 hours of your scheduled appointment time. (excisions, lasers, Botox, fillers, etc.) COLLECTION AGENCY A. In the event it is necessary to refer your account to a collection agency, you will be responsible for all fees of any collection agency, which may be based on a percentage at a maximum of 30% of the debt, and all charges accrued, including attorney fees, court costs, late fees, an 8% interest fee, and all McLean Dermatology and Skincare Center PLLC administrative fees. PRIVACY PRACTICES A. By signing below, you authorize the release of any medical or other information necessary to process claims related to medical services received by yourself or your dependent. You assign all medical payment on your behalf or that of your dependent for services provided to be issued to McLean Dermatology and Skincare Center, PLLC, 6849 Old Dominion Dr. Suite 340, McLean, VA B. We are required by law to provide you with a copy of our Notice of Privacy Practices and our Financial Agreement. By signing this agreement you acknowledge that you have received and read our Notice of Privacy Practices and dully understand and accept the terms of the McLean Dermatology and Skincare Center Notice of Privacy Practices and Financial Agreement. Patient Name Signature of Patient or Parent/Guardian Date Signed Updated December
5 Consent to Treat Patient WITHOUT Parent/Legal Guardian Present By law, any child under the age of 18 years of age cannot be seen by a doctor without consent from a parent or legal guardian. If the minor arrives with someone other than a parent or legal guardian, we must have written permission from the parent or legal guardian that this person has been appointed to act your behalf. Minor s Name: Date of Birth: Last First Middle Allergies: Current Medications: Chronic Conditions: For those occasions when you may not be with your child, please list those individuals who may give us consent to see your child: Name Name LIMITATIONS: Identify any specific limitations on the kinds of medical services for which this authorization is given. (If none, state none ) Check here if you wish to give consent for the minor to receive medical care without an accompanying adult, which shall be in effect for: Date ONLY Indefinitely, until consent is revoked in writing AUTHORIZATION I (parent/legal guardian name) request and authorize McLean Dermatology & Skincare Center and its personnel to deliver medical care to my child listed above as may be deemed necessary or advisable in the diagnosis and treatment of a minor child. I am also aware that, in addition to making medical decisions on my behalf, that the adult presenting the child is responsible for payment of the patient portion at the time of service. I have the legal right to preauthorize McLean Dermatology and Skincare Center and its personal to deliver medical treatment and services to my child. Medical care and interventions may include, but are not limited to: medical evaluation, physical exam, or lab work. (Examples include, prescriptions, blood tests, biopsies, throat or nasal swabs, urine tests, wart treatment and liquid nitrogen, minor suturing after biopsies, etc.) I have read, understand, and give my consent as stipulated above. My signature means that I have read this form and/or have had it read to me and explained in the language that I can understand. Parent or Legal Guardian (Please Print) Parent or Legal Guardian Signature Date 5
6 To Request Information or File a Complaint If you have questions, would like additional information, or want to report a problem regarding the handling of your information, you may contact Lily Talakoub, M.D. (Business Owner) 6849 Old Dominion Drive, Suite 340 McLean, VA or call Additionally, if you believe your privacy rights have been violated, you may file a written complaint at our office by delivering the written complaint to Lily Talakoub, M.D. (Business Owner). We cannot, and will not, require you to waive the right to file a complaint with the Secretary of Health and Human Services (HHS) as a condition of receiving treatment from our office. We cannot, and will not, retaliate against you for filing a complaint with the Secretary of Health and Human Services. Other Disclosures and Uses Directory [Only for hospitals.] Unless you notify us that you object, we will use and disclose your name, location, general condition, and religious affiliation in a hospital directory. This information may be provided to members of clergy and, except for religious affiliation, to other people who ask for you by name. Communication with Family Using our best judgment, we may disclose to a family member, other relative, close personal friend, or any other person you identify, health information relevant to that person's involvement in your care or in payment for such care if you do not object or in an emergency. Notification Unless you object, we may use or disclose your protected health information to notify, or assist in notifying, a family member, personal representative, or other person responsible for your care, about your location, and about your general condition, or your death. Research We may disclose information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information. Disaster Relief We may use and disclose your protected health information to assist in disaster relief efforts. Organ Procurement Organizations Consistent with applicable law, we may disclose your protected health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant. Food and Drug Administration (FDA) We may disclose to the FDA your protected health information relating to adverse events with respect to food, supplements, products and product defects, or post- marketing surveillance information to enable product recalls, repairs, or replacements. Workers Compensation If you are seeking compensation through Workers Compensation, we may disclose your protected health information to the extent necessary to comply with laws relating to Workers Compensation. Public Health As authorized by law, we may disclose your protected health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability; to report reactions to medications or problems with products; to notify people of recalls; to notify a person who may have been exposed to a disease or who is at risk for contracting or spreading a disease or condition. Abuse & Neglect We may disclose your protected health information to public authorities as allowed by law to report abuse or neglect. Employers We may release health information about you to your employer if we provide health care services to you at the request of your employer, and the health care services are provided either to conduct an evaluation relating to medical surveillance of the workplace or to evaluate whether you have a work- related illness or injury. In such circumstances, we will give you written notice of such release of information to your employer. Any other disclosures to your employer will be made only if you execute a specific authorization for the release of that information to your employer. Correctional Institutions If you are an inmate of a correctional institution, we may disclose to the institution or its agents the protected health information necessary for your health and the health and safety of other individuals. Law Enforcement We may disclose your protected health information for law enforcement purposes as required by law, such as when required by a court order, or in cases involving felony prosecution, or to the extent an individual is in the custody of law enforcement. Health Oversight Federal law allows us to release your protected health information to appropriate health oversight agencies or for health oversight activities. Judicial/Administrative Proceedings We may disclose your protected health information in the course of any judicial or administrative proceeding as allowed or required by law, with your authorization, or as directed by a proper court order. Serious Threat To avert a serious threat to health or safety, we may disclose your protected health information consistent with applicable law to prevent or lessen a serious, imminent threat to the health or safety of a person or the public. For Specialized Governmental Functions We may disclose your protected health information for specialized government functions as authorized by law such as to Armed Forces personnel, for national security purposes, or to public assistance program personnel. Coroners, Medical Examiners, and Funeral Directors We may release health information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release health information about patients of Covered Entities to funeral directors as necessary for them to carry out their duties. Other Uses Other uses and disclosures, besides those identified in this Notice, will be made only as otherwise required by law or with your written authorization and you may revoke the authorization as previously provided in this Notice under "Your Health Information Rights Website If we maintain a website that provides information about our entity, this Notice will be on the website. 6
DERMATOLOGIC CENTER FOR EXCELLENCE ANTHONY S. DEE, MD DANIELLE JOHNSTON, RPA-C LISA PORTER, RPA-C PATIENT REGISTRATION FORM
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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
Last Name _ First Name Middle Initial _ Social Security Number: Birthdate Age Sex (Circle one) M F Address _City State Zip Home Phone # Cell Work
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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
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
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Name SS# LAST FIRST MIDDLE INITIAL. Address STREET CITY APT # STATE ZIP. Alternate Address STREET CITY STATE ZIP
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Pierre G. Labrecque, M.D. 120 North Miller Street, Building C Santa Maria, CA (805) Office (805) Fax
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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 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
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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. 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,
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
Pierre G. Labrecque, M.D. 120 North Miller Street, Building C Santa Maria, CA (805) Office (805) Fax
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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
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
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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
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
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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
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Would you like to receive our monthly ed newsletter? Yes! No thanks.
Phone: 540-885-4500 Fax: 540-885-4600 PATIENT DEMOGRAPHIC INFORMATION PLEASE PRINT NAME: AGE: (LAST) (FIRST) (MIDDLE) SEX: M F (CIRCLE) DATE OF BIRTH: PERSON RESPONSIBLE FOR ACCOUNT: MAILING ADDRESS: (CITY)
Patient Information 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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Address: City/State: Zip: Employer: Occupation: Address: Phone: Emergency Contact: Phone: ( ) - PRIMARY INSURANCE: Address:
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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
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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
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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:
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,
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
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:
REGISTRATION FORM (Please Print)
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(Last) (First) (Middle) Home Phone: Work: Cell: (Include Extension, if applicable) (OK to Text )
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The Dermatology Center at Ladera Financial and Care Consent Agreement
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