New Patient Form. Patient Name: DOB: Date: Sex: Race: Social Security Number: Driver s License Number: Address: City/ State/ Zip

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Download "New Patient Form. Patient Name: DOB: Date: Sex: Race: Social Security Number: Driver s License Number: Address: City/ State/ Zip"

Dennis Lambert
5 years ago
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1 New Patient Form Patient Name: DOB: Date: Sex: Race: Social Security Number: Driver s License Number: Address: City/ State/ Zip Phone (Primary) (Secondary) May we leave a detailed message on your answering machine or voice mail? yes no Emergency Contact Name: Phone: Relationship to Patient : Insurance Information Primary Insurance: Policy #: Policy Holder s Name: Policy Holder s Date of Birth: Responsible Party s Name: Secondary Insurance: Policy#: Policy Holder s Name: Policy Holder s Date of Birth: Primary Care Physician Primary Care Doctor : Phone Number : Name of Referring Physician( if applicable) If not a consult, how did you hear about our practice? Preferred Pharmacy Pharmacy Name, location and phone number : What skin problem(s) are we seeing you for today? **Please be aware that, unless scheduled as one, a complete skin exam requires a separate visit to ensure we have the necessary time to be thorough.** To stay up to date on our monthly specials and giveaways, sign up for our newsletter! YES NO

2 Past Medical History: (please circle all that apply) Anxiety Arthritis Asthma Atrial fibrillation Bone Marrow Transplantation BPH Breast Cancer Colon Cancer COPD Coronary Artery Disease Depression Diabetes End Stage Renal Disease GERD Hearing Loss Hepatitis High Blood pressure HIV/AIDS High Cholesterol Hyperthyroidism Hypothyroidism Leukemia Lung Cancer Lymphoma Prostate Cancer Radiation Treatment Seizures Stroke NONE Other Past Surgical History : (please circle all that apply) Appendix Removed Bladder Removed Mastectomy (Right, Left, Bilateral) Lumpectomy (Right, Left, Bilateral) Breast Biopsy (Right, Left, Bilateral) Breast Reduction Breast Implants Colectomy: Colon Cancer Resection Colectomy: Diverticulitis Colectomy: IBD Gallbladder Removed Coronary Artery Bypass Mechanical Valve Replacement Biological Valve Replacement Heart Transplant Joint Replacement, Knee (Right, Left, Bilateral) Joint Replacement, Hip (Right, Left, Bilateral) Joint Replacement within last 2 years Kidney Biopsy Kidney Removed (Right, Left) Kidney Stone Removal Kidney Transplant Liver Transplant Ovaries Removed: Endometriosis Ovaries Removed: Cyst Ovaries Removed: Ovarian Cancer Ovaries: Tubal Ligation Pancreas Removed Prostate Removed: Prostate Cancer Prostate Biopsy TURP (Prostate Removal) Spleen Removed Testicles Removed (Right, Left, Bilateral) Tonsillectomy Hysterectomy: Fibroids Hysterectomy: Uterine Cancer NONE Other Skin Disease History: (please circle all that apply) Acne Asthma Blistering Sunburns Dry Skin Eczema Flaking or Itchy Scalp Hay Fever/Allergies Poison Ivy Psoriasis NONE Other

3 Skin Cancer History: (please mark all that apply and write the location(s) and date(s) in the space provided) Actinic Keratoses Basal Cell Carcinoma Melanoma Precancerous Moles Squamous Cell Carcinoma Other NONE Do you wear Sunscreen? Yes No If yes, what SPF? Do you tan in a tanning salon? Yes No Do you have a family history of Melanoma? Yes No If yes, which relative(s)? Medications: (Please enter all current medications) List name, Dose, Frequency Medication Name Dose Frequency Allergies: (Please enter all DRUG allergies) Social History: Cigarette Smoking: Currently Smokes Never smoked Former Smoker Alcohol Use: None Less than 1 drink per day 1-2 drinks per day 3 or more drinks per day Other

4 Family Medical History (Only first degree relatives) *INCLUDE ANY SKIN CANCER* Review of Systems: Are you currently experiencing any of the following? (Please check yes or no for the following) Symptom Yes No Fever/Chills Dry eyes/blurry vision Diarrhea/constipation Joint aches/muscle weakness Nosebleeds Headaches Shortness of breath Depression/anxiety Thyroid disorder Chest pain Skin rash or lesions Allergy to lidocaine or other numbing agent Dry lips/chelitis Other Symptoms: ALERTS: (please circle all that apply) Pregnant Planning a pregnancy Breastfeeding Chemotherapy Blood thinners Pacemaker Require antibiotics prior to a surgical procedure Cold sores/hsv HIV/Hepatitis C

5 Inverness Dermatology, LLC Patient Contact Information Sheet Patient Name: Date of Birth: Social Security Number OR Driver s License Number (required by HIPAA law): Any physician, staff, employee or representative of Inverness Dermatology, LLC has my permission to discuss my account and medical conditions which may include symptoms, treatments, diagnosis, test results, medications or any other type of protected health information with the following persons in order to facilitate and coordinate my care, treatment and payment: Name Relationship Phone Number(s) Name Relationship Phone Number(s) Name Relationship Phone Number(s) Name Relationship Phone Number(s) I understand that authorizing the release of my information to the above individual(s) is voluntary and does not affect my access to treatment. I can refuse to sign this form. I can revoke it by writing to Inverness Dermatology, LLC or completing a new form at any time. This authorization will remain in effect until I change or revoke it. I understand that if information is shared with the above individuals it may be subject to redisclosure by the individual(s). Patient Signature: Date: Copy given to patient

6 Insurance Screening Questions The government has required all medical offices to ask certain screening questions. We appreciate your cooperation. If you have any questions, please do not hesitate to ask. Patient Name: Patient Birthday: Vaccinations: Any age: Have you had a flu shot in the past 12 months? YES NO As medical professionals, we recommend patients of all ages be vaccinated every year Over 65 years: Have you had a pneumonia vaccine? YES NO Tobacco: Over 14 years: Do you smoke? YES* NO If yes, how many packs per day? And how many years? packs per day, years Alcohol: Over 65 years: Have you had more than 4 drinks in a day in the past year? YES* NO Males between years: Have you had more than 5 drinks in a day in the YES* NO past year? Females between years: Have you had more than 4 drinks in a day in the past year? YES* NO *If YES, how many days in the past year have you exceeded this number? days *If you answered YES to the alcohol or tobacco questions, we recommend quitting. You can ask any health care provider about resources to help you in this process, some of which are listed below

7 Financial Responsibility Agreement CO-PAYMENTS: Co-payments are required at the time of service. If you are unable to pay your co-pay and would like us to bill you, a $20 billing fee will be added. BALANCES: All balances must be paid in full before seeing the medical provider. If you have previously had a balance that went over 90 days without payment, we now require you to keep a credit card on file. FMLA/ CANCER POLICIES/ DISABLITY FORMS: There is a $25.00 fee for form completion. The fee is not reimbursed by your insurance, and the payment is required prior to completion. Once completed, it is our policy that you must pick up the form in office. We will not mail, or fax these forms. REFERRALS: If your insurance requires you to have a referral from a primary care physician, it must be obtained prior to seeing one of our medical providers. It is the patient s responsibility to obtain the referral from his/her primary care physician. If we have not received the referral, payment in full is required at the time of service or your appointment will need to be rescheduled. BLOOD WORK/ BIOPSIES/ CULTURES: Your medical provider may order blood work, biopsies or cultures, etc. in order to diagnose your condition. Our practice utilizes an outside laboratory, AEL Lab and an outside pathology lab to process these specimens. We will forward your information, including insurance, so that a claim can be filed. However, please keep in mind that you may receive a bill from the outside lab for these services. SURGICAL SERVICES/ PDT/ LASER PROCEDURES: Our office staff will contact the patient s insurance company to determine if a pre-certification is required. However it is the patient s responsible to know his/her benefits, we do not quote pricing. We are happy to provide the patient with the codes, so that the patient may contact his/her insurance to determine his/her financial responsibility before the service is provided. Because there are numerous insurance policy contracts, each one being different, it is our policy that the patient must be knowledgeable of their contract and benefits with their insurance policy. Due to the increase cost for billing, patient s failure to fulfill their financial obligations, and other changes in healthcare regulations, it is necessary for our office to implement the above policies. If you have any questions or concerns regarding these polices, you may contact our Office Manager. I fully understand my financial responsibility for services rendered at Inverness Dermatology and Laser, and understand that failure to comply with these policies will result in having to reschedule any appointments until I am able to fulfill my responsibility. Signature of Patient, or Responsible Party Date Printed Name of Patient/ Responsible Party

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