History and Intake Form. Date of Birth:
|
|
|
- Elisabeth Nicholson
- 5 years ago
- Views:
Transcription
1 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 Marrow Transplantation Breast Cancer Colon Cancer COPD Coronary Artery Disease Depression Diabetes End Stage Renal Disease (Kidney) GERD Hearing Loss Hepatitis Hypertension (High Blood Pressure) HIV/AIDS High Cholesterol Hyperthyroidism (High) Hypothyroidism (Low) Leukemia Lung Cancer Lymphoma Prostate Cancer Radiation Treatment Seizures Stroke Other Past Surgical History: (please check all that apply) Heart: Coronary Artery Bypass Heart: PTCA (Angioplasty/Stent) Heart: Mechanical Valve Replacement Heart: Biological Valve Replacement Joint Replacement, Knee Right Left Joint Replacement, Hip Right Left Ovaries Removed Reason: Transplant Type: Uterine: Hysterectomy -Reason: Other Skin Disease History: (please check all that apply) Actinic Keratoses Basal Cell Skin Cancer Eczema Hay Fever/ Seasonal Allergies Melanoma (location/year) Atypical Moles Psoriasis Squamous Cell Skin Cancer Other Do you have a family history of Melanoma? Yes No If yes, which relative(s)? Any other family history: PLEASE NOTE: Patients under 18 must be accompanied by a parent or legal guardian. TURN OVER TO COMPLETE
2 DERMATOLOGY ASSOCIATES Page Two History and Intake Form Name: Date of Birth: MEDICATIONS: Please list any prescription and non-prescription medications including pain relievers you are currently taking. Please include medication name, dosage and frequency. If you are taking more medications than space provides, please continue on a separate sheet of paper. Medication Dosage Frequency Medication Dosage Frequency Allergies: (Please enter all medications you are allergic to) Social History: Please check all that apply: Alcohol Use: None less than 1 drink a day 1-2 drinks per day 3 or more per day Smoking: Never smoked Former smoker Current smoker Please check all that currently apply: Alerts: Review of Systems: Allergy to adhesive Problems with bleeding Allergy to lidocaine Problems healing Allergy to topical antibiotic ointments Abnormal scarring Artificial heart valve New or changing moles Artificial joints within the past two years Swollen glands Blood thinners Defibrillator MRSA Pacemaker Rapid heartbeat with epinephrine Do you require antibiotics prior to a surgical procedure? Are you pregnant or currently trying to get pregnant? Allergy to Latex Allergy to Iodine Pharmacy Name: Phone # ( ) Pharmacy Street: City: May we obtain a history of prescriptions directly from your pharmacy? Yes No Signature: Date:
3 CENTER FOR SURGICAL DERMATOLOGY & CENTER FOR SURGICAL DERMATOLOGY AMBULATORY SURGERY CENTER Patient Demographics (Please print) Patient s Name: Name I Preferred to be Called: Home Address: City: State: Zip: Home Phone: Cell Phone: Work Phone: May we send you information via regarding cosmetic specials? Yes No Date of Birth: Social Security #: Race: African American American Indian Asian Caucasian Hispanic Marital Status: Married Single Widow/Widower Divorced Sex: Male Female Employer: Occupation: Employer Address: City: State: Zip: Spouse s Name if applicable: Date of Birth: Emergency Contact: Phone Number: Relationship: How were you referred to our office? Physician RSVP Mailer Ad in Suburban News Friend Yellow Pages Skin Cancer Screening Family Self Other Primary Care Physician: Address: Referring Physician: Address: City: State: Zip: City: State: Zip: Phone Number: Phone Number: 1 Created 8/18/2011
4 Patient Name: Name: Date of Birth: Fiscally Responsible Party Information (If Other Than Patient) Home Address: City: State: Zip: Home Phone: Home Insurance Information Is a referral required for this appointment? Yes No Primary Insurance: Policy #: Group #: Relationship to Patient: Self Spouse Domestic Partner Parent If subscriber other than patient, please complete the following information: Subscriber Name: Home Address: City: State: Zip: Date of Birth: Social Security# Secondary Insurance (If Applicable) Secondary Insurance: Policy #: Group#: Relationship to Patient: Self Spouse Domestic Partner Parent Subscriber Name (if other than patient): Date of Birth: Social Security# I certify that as the patient or responsible party I assign all insurance benefits to the Center for Surgical Dermatology (CSD) and/or Center for Surgical Dermatology Ambulatory Surgery Center (CSD ASC) and its physicians otherwise payable to me. I understand and agree that I am financially responsible for all charges whether or not paid by my insurance. My signature further authorizes CSD/CSD ASC to release information necessary to obtain payment of benefits. Signature of Patient (or Responsible Party & Relationship to Patient) Date Q:Forms/CSD/Patient Demographics 2 Created 10/16/2008
5 ! "!" # $ "! """!" # % & ' & & ( & &) $* $ " +,-!. - +,-!. - +-/!,( %,( )( 0 +-/!,( %,( )( 0 % ( % ( $" 2! $& ) 3 # 3 # # Q:Forms/CSD ASC/Forms to Use/Patient Privacy Instructions CSD ASD 6/08
6 RONALD J. SIEGLE, M.D. BRIAN P. BIERNAT, M.D. PETER C. SELINE, M.D. ANGELA S. CASEY, M.D. LINDA S. RUPERT, M.D. BRADLEY S. SODER, M.D. DEEPA LINGAM, M.D. NANDA CHANNAIAH, D.O. JAMES SAN FILIPPO, M.D. CHRISTINA A. SCHULTZ, MS, CNP Dear Patient: GENERAL DERMATOLOGY BILLING POLICY We are committed to providing you with the best possible care. With health care policy changing so rapidly, we do not have the ability we once did to know if you are approved for your visit. We wish to help you receive your maximum allowable benefits. In order to achieve these goals, we need your assistance and your understanding of our financial policy. 1. Your insurance is a contract between you and the insurance company. We are not a party to that contract. 2. We are contracted with many insurance companies and if you have a question regarding whether or not we are contracted with your plan, please contact your insurance company as they can best answer your questions. In order to be able to file your insurance claims, we must have a copy of your insurance cards as well as a picture I.D. We will submit to your primary and secondary insurances. When there is a change in your insurance plan, coverage or if at any time you receive a new/updated card, please notify us as soon as possible. Without this information, we may be unable to submit your claim to your insurance for payment. 3. Because our doctors are specialists, some insurance companies require a referral from your primary care physician. These can be faxed to us at If this is not done by the time of your appointment, you will be asked to either reschedule your appointment and contact your PCP, or pay for the services at the time you are seen. Any payments made at the time of service will be promptly refunded upon receipt of payment by the insurance company. 4. Your visit may generate two or more different bills. Depending on what you need to have done, you may receive statements from the following: a. Professional charges for DA has 11 providers including 8 physicians and 3 certified nurse practitioners (CNP**). All of our CNP's are board certified and have subspecialty training in dermatology. **CNP billing: Please note that your bill following a visit with a CNP may or may not show the name of that practitioner. More commonly it will show the name of one of our DA physicians, and it may or may not be one you have seen before. Which provider gets listed is determined by your insurance company rules (third-party carrier or Medicare) and not by us. This is often a confusing point so please keep it in mind. b. Pathology charges professional fees from the pathologist for the reading of your biopsy. Many insurance policies carry differing levels of coverage for in-network and out-of-network physicians. Again, you must clarify with your insurance that our physicians are a participating provider with your particular plan. It is also your responsibility to contact your insurance company prior to your procedure to clarify your own benefit levels, copays, deductibles, etc. as you are primarily responsible for the charges. 5. Mohs surgery procedures are approved by Medicare and need no prior authorization. 6. We are required by the state of Ohio to explain to patients the method of billing, including charges, for pathology services. If your physician performs a biopsy or excision, your specimen will be sent to a Board Certified Dermatopathologist (skin pathologist) for interpretation whenever possible. The Center for Surgical Dermatology/Dermatology Associates (CSD/DA) maintains contracts with multiple pathology labs to insure the highest quality of patient care and also to accommodate as - OVER Specializing in Dermatologic and Cosmetic Surgery: Skin Cancer Treatment, including Mohs Surgery Laser Surgery Liposuction Sclerotherapy Dermal Fillers Skin Rejuvenation Skin Care Products 428 County Line Road West Westerville, Ohio (614) Fax (614)
7 RONALD J. SIEGLE, M.D. BRIAN P. BIERNAT, M.D. PETER C. SELINE, M.D. ANGELA S. CASEY, M.D. LINDA S. RUPERT, M.D. BRADLEY S. SODER, M.D. DEEPA LINGAM, M.D. NANDA CHANNAIAH, D.O. JAMES SAN FILIPPO, M.D. CHRISTINA A. SCHULTZ, MS, CNP Dermatology Associates Billing Policy Page 2 many of our patients insurance companies as possible. In most cases, preparation of the skin biopsy for the pathologist is done here in the Center for Surgical Dermatology Pathology lab. You are billed for the preparation work from CSD ($90) and billed for the physician s reading from the outside pathology lab. If the skin pathologist requires additional studies on your tissue (special stains, immunochemistries) to help with making your diagnosis, those will appear on their bill whether to your insurance company or you. Occasionally we subcontract the pathology work. The amount CSD is charged for this service ranges from $ $ When CSD is able to bill your insurance directly or you directly instead of the pathology company doing the billing, we (CSD) can bill it for somewhat less than the approximate $ $ the pathology company would normally charge for the service. Please note that this policy applies to only some insurances. 7. Certain payments are due at the time when services are rendered including copays, outstanding balances, cosmetic procedures or products. We accept cash, personal checks, Visa, MasterCard, Discover and American Express. 8. If you do not have insurance, please call the billing office as soon as possible. Billing representatives are available Monday- Friday 7:30 am to 4:30 pm at , to answer any questions related to the above or to set up a payment plan if necessary. We understand that temporary financial problems may affect timely payment of your balance. We encourage you to communicate such problems so that we can assist you in the management of your account. 9. Cancellation Policy: As a courtesy to our other patients, please call at least 24 hours in advance to cancel or reschedule your appointments. We reserve the right to charge $25 for any appointment which is not cancelled with proper notice. We are pleased to have you as our patient. Your assistance as well as your patience with the above issues is appreciated as this will help make your overall visit with us go very smoothly. If you have any questions, please feel free to contact our office. I HAVE READ THE ABOVE FINANCIAL ARRANGEMENTS AND INSURANCE STATEMENT AND I REALIZE THAT PAYMENT IS MY OBLIGATION FOR COVERED AND NON-COVERED SERVICES REGARDLESS OF INSURANCE OR THIRD PARTY INVOLVEMENT. I AUTHORIZE THE PHYSICIAN TO FURNISH MY INSURANCE COMPANY WITH ANY INFORMATION REQUIRED AND MY INSURANCE BENEFITS TO BE PAID TO THE PHYSICIAN. Patient (Guarantor) Signature Patient DOB Patient Name Printed Date Q:Forms/CSD/GD Patient Billing Info Sheet Updated 11/2013 Specializing in Dermatologic and Cosmetic Surgery: Skin Cancer Treatment, including Mohs Surgery Laser Surgery Liposuction Sclerotherapy Dermal Fillers Skin Rejuvenation Skin Care Products 428 County Line Road West Westerville, Ohio (614) Fax (614)
8 N. State St. Ronald J. Siegle, M.D. Brian P. Biernat, M.D. Peter C. Seline, M.D. Angela S. Casey, M.D. It s easy to find the Center for Surgical Dermatology & Dermatology Associates 428 County Line Road West Westerville, Ohio TEL: FAX: Polaris 270 Gemini P kwy. 71 Pl. 71 Orion Pl. Rd. Worthington Cleveland Ave. Alkyre Run Dr. County Line Rd. Linda S. Rupert, M.D. Bradley S. Soder, M.D. Deepa Lingam, M.D. Nanda Channaiah, D.O. James San Filippo, M.D. 3 Maxtown Rd. Sunbury Rd Powell Road Gemini Place 71 Cleveland Polaris 670 Pk M axtown County 33 Line Sunbury We are located north and east of the I-71 & I-270 Interchange about 15 miles north of downtown Columbus. FROM THE NORTH, exit I-71 at Gemini Place/Polaris Parkway and turn left (East) at the light. Cross over the highway and turn right (South) on Orion Place to Polaris Parkway (0.3 miles). Turn left (East) on Polaris Parkway and go one mile to Cleveland Avenue. Turn right (South) on Cleveland Avenue and go 1/2 mile. Turn left (East) on County Line Road West. Immediately turn left on Alkyre Run Drive and turn right into our parking lot. FROM THE SOUTH, you have two options. The most direct would be to exit I-270 at Cleveland Avenue and go North 2 miles. Turn right on County Line Road West and take the immediate first left onto Alkyre Run Drive and turn right into our parking lot. A second option is to stay on I-71 north until Polaris Parkway. Turn right (East) on Polaris Parkway to Cleveland Avenue (Just over 1 mile). Turn right and go 1/2 mile south on Cleveland Avenue. Turn left on County Line Road West. Immediately turn left on Alkyre Run Drive and turn right into our parking lot. If you are coming from the north side of Franklin County or southern Delaware County it may be helpful to know that Powell Road (Route 750) coming from the west is continuous with Polaris Parkway which as you go east is continuous with Maxtown Road. CALL US IF YOU NEED DIRECTIONS Specializing in Mohs Surgery Skin Cancer Treatment Dermatologic and Cosmetic Surgery Liposuction Laser Surgery Sclerotherapy Skin Rejuvenation Skin Care Products
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
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:
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. 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
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:
PATI ENT INFORMATION Date=----~--- First Name: Ml: Last Name: ------------ Date of Birth: Sex: [ ] Male [ ] Female Address: City,State, Zip: Home Phone: Cell Phone:, Work Phone: Email Address: Marital
PATIENT 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
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:
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
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
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
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
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
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
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?
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
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 /
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 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
PATIENT REGISTRATION
PATIENT REGISTRATION Legal Name: Last First Middle Initial Billing Address: Street City/State Home Phone #: Cell Phone #: Work Phone #: Birthdate Zip Code How would you like to receive appointment reminders?
PATIENT 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
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
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 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
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
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
Maragh Dermatology. ( ) New Patient ( ) Name Change ( ) Address Change. Today s Date. Patient Name: Last First MI Male ( ) Female ( )
Maragh Dermatology ( ) New Patient ( ) Name Change ( ) Address Change Today s Date Patient Name: Last First MI Male ( ) Female ( ) DOB / / Marital Status ( ) Married ( ) Single ( ) Other Spouse Address
PATIENT 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
New Patient Form. Patient Name: DOB: Date: Sex: Race: Social Security Number: Driver s License Number: Address: City/ State/ Zip
New Patient Form Patient Name: DOB: Date: Sex: Race: Social Security Number: Driver s License Number: Address: City/ State/ Zip Phone (Primary) (Secondary) Email May we leave a detailed message on your
PATIENT INFORMATION Please Complete All Sections on All Pages
PATIENT INFORMATION Please Complete All Sections on All Pages PREFERRED PHONE OK to leave message: Yes No ALTERNATE PHONE OK to leave message: Yes No We will utilize your preferred phone number to communicate
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
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)
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
VALLEY DERMATOLOGY, LLC 2611 West Main Street, Ste 1 Waynesboro, VA Fax:
VALLEY DERMATOLOGY, LLC 2611 West Main Street, Ste 1 Waynesboro, VA 22980 540-221-6702 Fax: 540-221-6704 PATIENT DEMOGRAPHICS Patient Name: Birth Gender: Male or Female DOB: Social Security Number: Guarantor
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
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 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
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
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 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
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)
New Patient Registration
New Patient Registration Today s Date: e-mail: Patient Information First Name M.I. Last Name Address City State Zip Phone Work Cell Date of Birth Age SSN Occupation Employer Language English Spanish Other
19910 S. Tamiami Trail, Suite B Hillary Cachet, PA-C Estero, FL (239)
FLORIDA COASTAL DERMATOLOGY ASSOCIATES Naples 801 Anchor Rode Dr., Suite 100 Lisa D. Zack, M.D Naples, FL 34103 Bradley T. Kovach, M.D. (239) 263-1717 Janalea Thomas, PA-C Estero Lidia Starr, PA-C 19910
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
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
Soderma Dermatology. General, Surgical & Cosmetic
S D General, Surgical & Cosmetic Welcome to Soderma, General, Surgical & Cosmetic Dermatology. We are a comprehensive dermatology practice, providing a full range of medical, surgical and cosmetic dermatologic
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
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.:
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
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
PATIENT INFORMATION SHEET. Reason(s) for Visit: (chief complaint)
PATIENT INFORMATION SHEET Patient : Pharmacy: Date of Birth: Pharmacy Phone Number: Reason(s) for Visit: (chief complaint) Past Medical History: (Check all that apply) Anxiety Arthritis Asthma Atrial Fibrillation
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
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,
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
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
PATIENT INFORMATION SHEET. Reason(s) for Visit: (chief complaint)
PATIENT INFORMATION SHEET Patient : Pharmacy: Date of Birth: Pharmacy Phone Number: Reason(s) for Visit: (chief complaint) Past Medical History: (Check all that apply) Anxiety Arthritis Asthma Atrial Fibrillation
Pierre G. Labrecque, M.D. 120 North Miller Street, Building C Santa Maria, CA (805) Office (805) Fax
(805) 739-0033 Office (805) 739-1712 Fax Welcome to DermaSpa MED and thank you for entrusting us with your medical needs. Your care and satisfaction is our priority and we are committed to providing you
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
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
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):
Financial Policy. 158 Front Royal Pike Suite 303 Winchester, VA (540) Office * (540) Fax. 103 W. South St.
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
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 SS# LAST FIRST MIDDLE INITIAL. Address STREET CITY APT # STATE ZIP. Alternate Address STREET CITY STATE ZIP
Date: Patient Information Name SS# LAST FIRST MIDDLE INITIAL Date of Birth Gender Male Female Marital Status Single Married Divorced Widowed Address STREET CITY APT # STATE ZIP Alternate Address STREET
REGISTRATION FORM (Please Print)
CENTRAL FLORIDA DERMATOLOGY, ALFREDO E. GONZALEZ, MD, PA REGISTRATION FORM (Please Print) Primary Care Physician: PATIENT INFORMATION Patient s last name: First: Middle: Mr. Mrs. Miss Ms. Marital status
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
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 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:
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
Illinois Dermatology Institute Patient Information (Please Print) Today s Date / /
Illinois Dermatology Institute Patient Information (Please Print) Today s Date // Name: Last First MI Mailing Address: Street City State Zip code Home Phone( ) Alternate Phone( ) Email Ok to leave message:
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,
Pierre G. Labrecque, M.D. 120 North Miller Street, Building C Santa Maria, CA (805) Office (805) Fax
120 North Miller Street, Building C Santa Maria, CA 93454 (805) 739-0033 Office (805) 739-1712 Fax Welcome to DermaSpa MED and thank you for entrusting us with your medical needs. Your care and satisfaction
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:
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 (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
NEW PATIENT INFORMATION (PLEASE PRINT)
NEW PATIENT INFORMATION (PLEASE PRINT) PATIENT'S SS# DATE PATIENT'S NAME HOME PHONE NO. MAILING ADDRESS CITY, & STATE ZIP EMAIL MALE FEMALE DATE OF BIRTH AGE MARITAL STATUS: SINGLE or MARRIED PATIENT'S
Metrolina Dermatology and Skin Surgery Specialists Park Road, Suite 100 Charlotte, NC
Metrolina Dermatology and Skin Surgery Specialists 10502 Park Road, Suite 100 Charlotte, NC 28210 www.metrolinadermatology.com Dear Patient, We thank you for choosing Metrolina Dermatology and Skin Surgery
PATIENT 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
Friendswood Dermatology REGISTRATION INFORMATION Page 1-2. Name First MI Last
Friendswood Dermatology REGISTRATION INFORMATION Page 1-2 Patient Information: Today s Date Name First MI Last Address Street City State Zip Home Phone ( ) Work Phone ( ) Cell Phone ( ) Email: @ Birth
NEW PATIENT REGISTRATION FORM
NEW PATIENT REGISTRATION FORM Date: / / Patient (Legal) Name: Nickname: SSN (>Age 18): Date of Birth: Sex:! Male! Female Driver s License #: State: Mailing Address: (Street/PO Box, City, State, Zip Code)
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
We look forward to meeting you soon!
Dear New Client: We are pleased to welcome you to our practice! Thank you for allowing us to serve your health care needs. We are enclosing with this letter our new patient information forms. Please complete
PATIENT INFORMATION: NAME: Mr. Mrs. Ms. Miss Last First MI Circle one PHONE: (Home) (Cell) ADDRESS: Street Address City State Zip Code
PATIENT INFORMATION: Date: NAME: Mr. Mrs. Ms. Miss Last First MI Circle one PHONE: (Home) (Cell) E-MAIL ADDRESS: ADDRESS: Street Address City State Zip Code BIRTHDATE: / / AGE: SSN: SEX: M F OCCUPATION:
Alaska Center for Dermatology, P. C Piper Street Suite T4-020 Anchorage, AK telephone fax
3841 Piper Street Suite T4-020 Anchorage, AK 99508 telephone 907.646.8500 fax 907.646.9760 Please print all information clearly. Patient Patient Registration Form Name of Birth / / first middle initial
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
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
Illinois Dermatology Institute
Illinois Dermatology Institute PATIENT INFORMATION (Please Print) Today s _/ / Name: Last First M.I. Mailing Address: Street City State Zip Code Home Phone ( ) Work Phone ( ) Cell Phone ( ) OK to leave
(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.
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
INSURANCE INFORMATION (Please present insurance cards at the time of check in)
421 N. RODEO DR., SUITE T-7, BEVERLY HILLS, CA 90210 T: (310)274-5372 F: (310)274-5380 Date: / / PATIENT REGISTRATION FORM Name: Jr. Sr. Last First Middle Prefer to be called: Title: Mr. Mrs. Ms. Miss
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
ADVANCED DERMATOLOGY & SKIN SURGERY, P.A.
ADVANCED DERMATOLOGY & SKIN SURGERY, P.A. Thank you for scheduling an appointment with Advanced Dermatology. We are committed to your treatment and well being and will work hard to serve your needs. In
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:
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:
Welcome to Florida Eye Institute!
Welcome to Florida Eye Institute! We look forward to greeting you as a new patient. Having served the Vero Beach community for over 30 years, it is our steadfast goal to help you achieve the best vision
Last Name: First Name: M / F Today s Date: Birthdate: Age: Height: Weight:
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
Address: Primary Insurance Co. Name: Policy Holder:
Today s Date: / / PATIENT INFORMATION Name: Last First M.I. Mailing Address: Street City State Zip Code Home Phone: Work Phone: Cell Phone: OK to leave message: Yes No OK to leave message: Yes No OK to
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: