REGISTRATION FORM (Please Print)

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Olivia Ward
6 years ago
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1 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 / Sep / Wid (Former name): Birth date: Home phone no.: Cell phone no.: Age: Sex: / / ( ) ( ) q M q F Street address: Social Security no.: Pharmacy: Location P.O. Box: City: State: ZIP Code: Occupation: Employer: Employer phone no.: address for access to the Patient Portal: ( ) I authorize Newnan Dermatology to access my pharmacy in order to coordinate my medications: Chose clinic because/referred to clinic by (please check one box): q Dr. q Insurance Plan q Hospital q Family q Friend q Close to home/work q Yellow Pages q Other INSURANCE INFORMATION (Please give your insurance card to the receptionist.) Person responsible for bill: Birth date: Address (if different): Home phone no.: / / ( ) Is this person a patient here? q q Occupation: Employer: Employer address: Employer phone no.: ( ) Please indicate primary insurance: Subscriber s name: Subscriber s S.S. no.: Birth date: Group no.: Policy no.: Co-payment: Patient s relationship to subscriber: q Self q Spouse q Child q Other Name of secondary insurance (if applicable): Subscriber s name: Group no.: Policy no.: Patient s relationship to subscriber: q Self q Spouse q Child q Other

2 HIPAA PRIVACY ACT I understand I can obtain a copy of Newnan Dermatology s HIPAA privacy act. Initials CONSENT TO TREAT I consent to treatment rendered by the physician and his/her directed medical staff at Newnan Dermatology. I understand that Newnan Dermatology utilizes Physician Assistants to render health care. With my consent, Newnan Dermatology may use and disclose protected health information (PHI) about me to carry out treatment, payment, and healthcare operations. RELEASE OF INFORMATION I authorize the release of my medical information to the following: Name/Relationship Date of Birth Phone Address I authorize the release of my billing information to the following: Name/Relationship Date of Birth Phone Address Patient/Guardian signature: Date: IN CASE OF EMERGENCY Name of friend or relative (not living at same address): Relationship to patient: Home phone no.: Work phone no.: ( ) ( ) FINANCIAL POLICY The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. This responsibility applies to copay, deductible, co-insurance, full payment if uninsured and for cosmetic procedures that are not covered by insurance. We do not file insurance for any cosmetic services. I also authorize Newnan Dermatology or insurance company to release any information required to process my claims. Check Policy: If your check is dishonored or returned for any reason, we will debit your account for the amount of the check plus a processing fee of $ Collection Policy: We employ an outside collection agency for delinquent accounts. Fees will be incurred for their services. Appointment Show Policy: We understand that there are times when you must miss an appointment due to emergencies or obligations for work or family. However, when you do not call to cancel an appointment you may be preventing another patient from getting much needed treatment. Conversely, the situation may arise where another patient fails to cancel and we are unable to schedule you for a visit due to a seemingly full appointment book. If an appointment is not cancelled at least 24 hours in advance you will be charged a twenty-five dollar ($25) fee; this will not be covered by your insurance company. Waiver of medical necessity: Your insurance is a contract between you and your insurance company. Coverage benefits will vary based on your personal policy. Please contact them directly with any questions about your specific coverage. Laboratory/pathology test processed outside of our office include biopsies and blood work. We will provide the laboratory with your insurance information and they will bill you directly for any remaining balance. Pathology test are performed in Newnan Dermatology s specialized Dermatology Lab. These charges will be filed with your insurance and you will be billed by Newnan Dermatology for any remaining balance. Patient/Guardian signature Date

3 Name Patient ID: Date: Preferred Pharmacy Information: Name: _ Phone Number: City or Zip Code: Past Medical History: Select any of the following medical conditions you currently have: Anxiety Arthritis Asthma Atrial Fibrillation Bone Marrow Transplant BPH (Enlarged prostate) Breast Cancer Colon Cancer COPD (Emphysema) Coronary Artery Disease Depression Diabetes Kidney Failure GERD (Reflux / Heartburn) Hearing Loss Hepatitis Hypertension HIV / AIDS Hypercholesterolemia Thyroid Disease Leukemia Lung cancer Lymphoma Prostate Cancer Radiation Treatment Seizures Stroke NONE Other: Past Surgical History: Have you had any surgeries on the following organs? Appendix (Appendectomy) Breast: Breast Biopsy Breast: Lumpectomy (Right, Left, Bilateral) Breast: Mastectomy (Right, Left, Bilateral) Colon (Colectomy) Gallbladder (Cholecystectomy) Heart: Coronary Artery Bypass Surgery Heart: Valve Replacement Heart: Stent Joint Replacement: Hip (Right, Left, Bilateral) Joint Replacement: Knee (Right, Left, Bilateral) Kidney: Kidney Biopsy Kidney: Kidney Stone Removal Kidney: Kidney Transplant Ovaries: Endometriosis Ovaries: Ovarian Cancer Ovaries: Ovarian Cyst Prostate: Prostate Biopsy Prostate: Prostate Cancer Prostate: TURP Skin: Basal Cell Carcinoma Skin: Melanoma Skin: Skin Biopsy Skin: Squamous Cell Carcinoma Testicles (Orchiectomy) Uterus: Fibroids Uterus: Uterine/Cervical Cancer NONE Other:

4 Have you had any of the following skin conditions? Acne Actinic Keratoses Asthma Basal Cell Skin Cancer Blistering Sunburns Dry Skin Eczema Flaking or Itchy Scalp Hay Fever / Allergies Melanoma Poison Ivy Precancerous Moles Psoriasis Squamous Cell Skin Cancer NONE Other: Skin Disease History: Do you Wear Sunscreen? If yes, what SPF? Do you have a family history of Melanoma? If yes, which relative? Do you tan in a tanning salon? Medication list: List all current medications: Name of medication Dosage Frequency Route of administration

5 Allergies: List all allergies and reactions if known: Social History MIPS Smoking Status (Please choose one): Current every day smoker Current someday smoker Former smoker Never smoker Unknown if ever smoked Start Smoking: mm/dd/yyyy Quit Smoking: mm/dd/yyyy Number of packs per day: Total years smoking: Alcohol Intake (Please choose one): ne 1 or less per day 1-2 per day 3 or more per day How many times in the past year have you had 5 or more drinks in a day for men, 4 or more drinks in a day for women? Influenza: Have you had your flu shot this year? NO If no, why? Pneumonia: Have you ever had the pneumonia vaccine? (If you are 65 or over) If no, why? Advance Care: Do you have an advance care plan or surrogate decision maker? If yes, who?

6 Family Health History: Please include only first-degree relatives: Review of Systems: Please Check yes or no for the following: Symptom Problems with bleeding Problems with healing Problems with scarring (hypertrophic or keloid) Alerts Please check yes or no for the following: Symptom Allergy to adhesive Allergy to lidocaine Allergy to topical antibiotic ointments Artificial heart valve Artificial joints within past two years Blood thinners (currently taking) Defibrillator MRSA (Staph infection) Pacemaker Premedication prior to procedure Rapid heartbeat with epinephrine Pregnancy or planning a pregnancy

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