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 Status: [ ] Single [ ] Married [ ] Widowed [ ] Divorced [ ] Other Primary Care Physician Name, City,State: Emergency Contact Name: Relationship:. Phone Number: Alt Phone Number: ----------- ----------- Respon s i b I e Party (if not patient) Name: Relationship:. Address:. City,State,Zip:. Primary Insurance {Please complete & present ins. cards to Receptionist.) Insurance Company: Policy ID Number: Group Number: Name of Policy Holder: DOB: Secondary Insurance (if applicable) Insurance Company: Policy ID Number: Group Number: Name of Policy Holder: DOB:,

Patient Name: DOB: Past Medical History: (please circle all that apply) Anxiety Coronary Artery Thyroid Problems Arthritis Disease Leukemia Asthma Depression Lung Cancer Atrial fibrillation Diabetes Lymphoma Bone Marrow End Stage Renal Prostate Cancer Transplantation Disease Radiation Treatment Breast Cancer GERO Seizures Colon Cancer Hearing Loss Stroke COPD Hepatitis High Blood pressure NONE HIV/ AIDS High Cholesterol 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: IBO 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 (Nephrectomy) Kidney Removed (Right, Left) Kidney Stone Removal Kidney Transplant Ovaries Removed: Endometriosis Ovaries Removed: Cyst Ovaries Removed: Ovarian Cancer Prostate Removed: Prostate Cancer Prostate Biopsy TURP (Prostate Removal) Spleen Removed Testicles Removed (Right, Left, Bilateral) Hysterectomy: Fibroids Hysterectomy: Uterine Cancer NONE Other ----------------------------

Patient Name: DOB: Skin Disease History: (please circle all that apply) Acne Dry Skin Poison Ivy Actinic Keratoses Eczema Precancerous Moles Asthma Flaking or Itchy Scalp Psoriasis Basal Cell Skin Cancer Hay Fever/ Allergies Squamous Cell Skin Blistering Sunburns Melanoma Cancer NONE Other 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) Allergies: (Please enter all allergies)

Patient Name:.DOB: Social History: (Please circle all that apply) Cigarette Smoking: Currently Smokes Has smoked in the past 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 ---------- ------------------ Family History (Only first degree relatives) Preferred Language: _ Race: -------- Ethnic Group: Preferred Pharmacy Name: Phone#: City or Zip code:

Patient Name: D0B: Review of Systems: Are you currently experiencing any of the following? (Please check yes or no for the following) Yes No Symptom Yes No Hay Fever Chest Pain Fever/Chills 1Night Sweats - Unintentional Weight Loss Tehyroicl Pr.0bleins Anxiety Depression Abdominal Pain Other Symptoms: ALERTS: (please circle all that apply) Allergy to adhesive Allergy to lidocaine Allergy to topical antibiotics Artificial heart valve Artificial joint replacement Blood thinners Defibrillator MRSA Pacemaker Require antibiotics prior to a surgical procedure Rapid heart beat with epinephrine Are you pregnant or currently trying to get pregnant? Yes No

Hermitage Dermatology Financial Policy Thank you for choosing our practice for your dermatology needs. Our providers and staff are committed to providing you with the best possible care. Please understand that payment is considered part of your treatment. The following is our Financial Policy which we require you to read and sign prior to any treatment. Payment We accept the following forms of payment: Cash, Check, Visa, MasterCard, American Express and Discover. Payment for services is due at the time services are rendered unless prior arrangements have been made with our office. We understand that temporary financial problems may affect timely payment of your balance. We encourage you to communicate any such problems to our Office Manager, so that we can assist you in management of your account with a payment plan. Please note the parent that accompanies the minor child/children to the appointment is responsible for any payment due. Insurance Your insurance policy is a contract between you and your insurance company. We are not a party to that contract. Our relationship is with you. We are credentialed with most insurance carriers. Please present your insurance card at the front desk so that we can file a claim on your behalf. All charges are your responsibility whether your insurance company pays or not. Please be aware that not all services are a covered benefit in all contracts. Some insurance companies and some employers decide what a covered benefit is and what is not. Patients are encouraged to check with their insurance carrier regarding benefits and coverage prior to their appointment. Fees for these services along with unmet deductibles and co-payments are due at the time of treatment. Our practice is committed to providing the best treatment for our patients and we charge what is usual and customary. Check Processing I give permission to Hermitage Dermatology (Lynn A. Colaiacovo, M.D., P.C.) to convert any paper check to an electronic transaction. Authorization & Acceptance of Financial Policy I authorize release of information concerning my (or my child's) health care, advise and treatment provided for the purpose of evaluating and administering claims for insurance benefits. I also hereby authorize payment of insurance benefits otherwise payable to me directly to Lynn A. Colaiacovo, M.D. PC. I understand that I am financially responsible for any balance not covered by my insurance. I certify that the information given by me in applying for payment is correct. I request that payment of authorized benefits be made on my behalf. A photocopy of these assignments shall be valid as the original. Printed Patient Name: DOB: --------------- --------- Signature of Patient or Personal Representative: Relationship to Patient: Date:

Ackn owledgment of Notice of Privacy Practices and Disclosure of Protected Health Information By signing the ac~nowledgement to the Notice of Privacy Practices and Disclosures of Protected Health Information, I further authorize Hermitage Dermatology (Lynn A. Colaiacovo, M.D., P.C.) to allow the following: To leave a detailed message on my answering machine or on my voicemail. [ ] YES [ ] NO To send me information via text message. To send me information via e-mail. To discuss my condition with the person(s) listed below. [ ] YES [ ] NO [ ] YES [ ] NO [ ] YES [ ] NO Name: Name: Name: --------------- --------------- Name: By signing this page you agree to allow Hermitage Dermatology (Lynn A. Colaiacovo, M.D., P.C.) to disclose your health information with those you have indicated above, and the means in which we may leave information for you. Also, you acknowledge that you have received a copy of the "Notice of Privacy Practices". Signature of Patient or Personal Representative: Relationship to Patient: Printed Name: Patient Name: Date: ----------------- ----------- DOB: ----------------- ----------- FOR OFFICE USE Changes to above authorized by the patient over the phone: Change Date Staff Initials