Welcome to Pacific Coast Dermatology. It is our pleasure to serve you in a setting staffed

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1 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 professionals in the field. Our staffs are committed to assisting you in every way possible, in keeping with the latest state of the art care. Enclosed you will find our standard forms that need to be filled out prior to being seen. By filling them out before you come in for your appointment you will save both yourself and us a great deal of time. Filling out the forms in advance will allow us to spend the maximum time in actual consultation with you. If you cannot have the forms filled out before you arrive for your appointment, please come in 15 minutes early so that you can complete them before you are seen. Also, please be sure to bring your insurance card, identification, and any secondary insurance you may have. We accept most PPO insurance plans and Medicare but not Medi-Cal. It is YOUR responsibility to know your co-pays and deductibles, and how your insurance will cover your visits if we are not preferred providers. We are setting aside a specific time in our day to serve you; please have the courtesy to advise us with at least 24 hours notice that you are unable to keep your appointment. It has unfortunately become necessary to impose a $50.00 charge for not showing up for an appointment and not notifying us in advance. This fee will apply to the 2nd failure to keep your appointment and for future No Shows. Please note that unless you are required to take aspirin, it is best to avoid taking it for three days prior to your appointment if you are having a biopsy, excision or injection. Also try to avoid taking any anti-inflammatory such as ibuprofen (Motrin, Advil & Aleve) or alcohol. We look forward to serving you! Regards, Dr. T. Anthony Hoang, FAAD Roswell Avenue, Suite 102,

2 Mr. Mrs. Miss Ms. Dr. PATIENT REGISTRATION Patient Today s Date Last Name First Name MI Address Street City State Zip Birthdate / / Age Social Security # Marital Status Single Married Widowed Divorced Home Phone ( ) Work Phone ( ) Cell Phone ( ) If Student: Full Time Part Time Name of School: Patient s Employer Spouse s Name Last name First name Patient s Occupation Spouse s date of birth / / In case of an emergency, whom can we contact? Name Relationship Phone Primary Care Physician: Referring Physician: City & State of Referring Physician: Specialty: Mailing address (if different from above) Street City State Zip PARENT OR RESPONSIBLE PARTY (if different from patient and required if patient is a minor) Name Last Name First Name MI Address Street City State Zip Home Phone ( ) Work Phone ( ) Birthday / / Social Security # Sex Male Female Do we have your permission to: you (non-medical) info, events and specials? YES NO If yes, Leave a message on your answering machine at home? YES NO Leave a message at your place of employment? YES NO Discuss your medical condition with any member of your household? YES NO If yes, whom: Patient Signature Relationship Date Revised 10/02/07 Page 2 of 6

3 MEDICAL HISTORY Name: Date: Reason for Visit: Do you have or have had any of the following? (if yes, please check) Acne Hepatitis/ Jaundice Actinic Keratosis High Blood Pressure Artificial heart valve HIV Artificial Joints or Metal Implant Keloids or Abnormal Scarring Asthma Kidney disease Atopic Dermatitis Liver disease Atrial Fibrillation Lung disease Autoimmune disease (Lupus, Rheumatoid Arthritis) Melanoma Bleeding disorder Migraines Blood Clots Multiple Sclerosis Cancer (what type? ) Pacemaker/ Defibrillator Chronic Fatigue/ Fibromyalgia Psoriasis Cold Sores/ Herpes Seasonal allergies Depression Skin Cancer (Basal or Squamous Cell Carcinoma) Diabetes Thyroid trouble Down s Syndrome Other conditions Epilepsy/Seizures Please list: Heartburn/ Ulcer/ Gastritis/ Reflux Heart disease Please list any medications, herbal supplements and/ or vitamins you are currently taking: Are you allergic to any medications? No Yes (Please list) Are you allergic to tape or bandages? No Yes (Please list) Are you allergic to any numbing medications or dental anesthesia? No Yes (Please list) Please list any other allergies Please list major surgeries: Date: Please list major hospitalizations: Date: Date: Date: Revised 10/02/07 Page 3 of 6

4 MEDICAL HISTORY Please list any relatives that have had any of the following conditions? (father, mother, grandfather, grandmother, brother, sister) Skin Cancer: Seasonal Allergies: Eczema: Psoriasis: Melanoma : Autoimmune disease: Diabetes: Cancer: Elevated Cholesterol: Other: How many of the following do you have? Brothers: Sisters: Sons: Daughters: Have you had any skin disease? (Please list) Have you ever had any skin cancer? (Please list) Do you develop skin rashes in reaction to Medication Food Environment? Please explain When you are exposed to sun, do you: Tan only Tan & Burn Burn Do you have any artificial joint(s)? Yes No Do you take Coumadin or other blood thinners? Yes No Do you take Aspirin daily? Yes No Do you need antibiotics before surgery or dental work? Yes No Are you pregnant or nursing? Yes No Are you allergic to any local anesthetic? Yes No Do you smoke? Yes No Do you exercise? Yes No Do you drink alcoholic beverages? Yes No Do you drink more than 20 alcoholic beverages/week? Yes No What is your occupation? What are your hobbies? Have you had any of the following? (please check all that apply) Weight change Neck stiffness Nausea Change in hair pattern Headache Fever Enlarged glands Vomiting Easy bruising Vision change Chills Sore throat Diarrhea Abnormal bleeding Ringing in ear Fatigue Chest pain Constipation Fainting Palpitation Blood in urine Seizures Leg swelling Joint pain Muscle ache Shortness of breath Irregular menstrual cycles Depression Recurrent nosebleeds Cough Nervousness Heat/Cold intolerance I certify that this history form is filled out completely and accurately. I have answered all questions truthfully and to the best of my knowledge. Patient s Signature Date Physician s Signature Date Revised 10/02/07 Page 4 of 6

5 Please present insurance card at the time of check in. INSURANCE INFORMATION Primary Insurance Name Name of Insured Ins. Address DOB of Insured Secondary Insurance Name Name of Insured Ins. Address DOB of Insured Insured ID # Insured ID # Group # Group # Employer Name Employer Address Employer Phone Relationship to Insured Employer Name Employer Address Employer Phone Relationship to Insured I authorize the release of medical information to my primary care or referring physician, to consultants if needed and as necessary to process insurance claims, insurance applications and prescriptions. I also authorize payment of medical benefits to Pacific Coast Dermatology (Dr. T. Anthony Hoang-Xuan, FAAD). I certify that the information given by me in applying for payment under Title XVIII of the Social Security Act is correct. I authorize the release of any information needed to act upon this request that payment of authorized benefits be made on my behalf. I assign payment for the unpaid charges of the physician for his services. I understand I am fully responsible for any remaining balances. I have read and understand the financial policy (please see attached) and agree to payment for services rendered and not covered by the insurance providers listed above. Signature of patient/policy holder/legal guardian Print Name Date HOW DID YOU HEAR ABOUT US? We would appreciate your response in following section. Physician (Dr. ) Family or Friend (name: ) Verizon Yellow Pages Chino Yellow Book NguoiViet Yearbook Chinese Yellow Pages Clipper Magazine Vietnamerican Church Bulletin Movies 8 Internet Search Insurance Website/Book Other: HEALTH ISSUES THAT INTEREST YOU Please check all that apply: Botox Cosmetic Therapy Acne / Acne Scars Spider Veins Treatments Facial Fillers Skin Care Plumping the Lips Skin Rejuvenation Laser Treatments Laser Resurfacing Sunscreen Reducing Wrinkles Liver / Age Spots Chemical Peels Eyelash Conditioning Other, please specify: Revised 10/02/07 Page 5 of 6

6 FINANCIAL POLICY Payment is required for all services at the time they rendered, unless you are in prepaid plan in which we participate. For patients with insurance coverage, applicable co-payments and annual deductibles will be collected at the time of service. The patient is responsible for any/all charges not paid by their insurance company. If you must cancel or reschedule an appointment, please call us at least 24 hours before your scheduled appointment. Pacific Coast Dermatology, Inc. charges a fee of $50 to all patients who missed their appointment or do not notify our office of the cancellation 24 hours in advance. Please remember that our policies are created to allow for effective scheduling and to ensure all patients wishing to receive services be accommodated. Please help us to better serve you. Some insurance policies require a referral from your primary care provider before we can see you. If you do not have your card or referral at the time of your appointment, insurance regulations requires that you sign a financial waiver and pay for your visit at the time of service. All copayments and deductibles are to be paid at the time of services. If you are not insured or coverage is not available, full payment must be paid at the time of service. We do not bill insurance for cosmetic procedures. Cosmetic procedures fees are due at the time of service. In some cases, patients will be asked to pay in advance. Should you need a claim form, there is a fee of $10 per form. We file all insurance claims for medical services and bill you any remaining balance, which is to be paid promptly. Any statement balance over 30 days past due, a monthly interest of 1½ percent or $5 (whichever is more) will be added to your account. Any account over 60 days past due will be sent to Transworld Systems for collections and $25 administrative fees will be added. Any checks returned NSF or for any other reasons, $20 fee will be added to your account to cover the bank charge. We participate in San Bernardino County District Attorney s Check Enforcement Program. If your check was returned for any reasons, we will notify you and request for payment plus $20 fee. We will also allow 10 days for you to comply with our request. If you failed to comply with our request or you do not contact us to arrange payment within the 10 days grace period, we will have no choice but refer your check to San Bernardino County DA s Check Enforcement Program. Patient/Legal Guardian Signature: Date: / / Medicare Patients Only I authorize any holder of medical or other information about me to release to the Social Security Administration and Center for Medicare Service, or its intermediaries or carrier, any information needed for this or a related Medicare claim. I permit a copy of this authorization to be used in place of the original, and request payment of medical insurance benefits either to myself or on my behalf to Pacific Coast Dermatology (Dr. T. Anthony Hoang-Xuan, FAAD) for any services furnished to by this office. Regulations pertaining to Medicare of benefits apply. This authorization is valid until revoked in writing. Signature: Date: / / Privacy Practice (HIPAA) By signing below, I acknowledge that I have a copy of Pacific Coast Dermatology s Notice of Privacy Practices. Signature: Date: / / Revised 10/02/07 Page 6 of 6