Cape Cod Dermatology, LLC - New Patient Intake

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Contact Information

If you do not have this number please call us for this information
(if different)

Please note: Appointments will be confirmed via phone, email and/or text unless you have requested otherwise.

If none please type 'none'

Insurance

Messages

Communication Permission

If desired, please list below a Relative or Friend that you would give permission to inform or discuss your Medical Information, Biopsy results, Plan of Care, or billing/insurance.

Required for Meaningful Use by The Federal Government

Pharmacy

Medications (Please list all current prescription medications as well as over-the-counter, vitamins, herbs & supplements)

Add Medications

Allergies (Please enter all allergies including drug, food, substance allergies, i.e. Latex)

Add Allergy

Past Medical History (Please check all that apply)

Skin Disease History (Please check all that apply)

Family Dermatology History

Social History

Review of Systems
Are you currently or recently experiencing any of the following? (Please check all that apply)

ALERTS (Please check all that apply)

Vaccines

Practice Policy Agreement

Before you sign this form, please read our Practice Policy Agreement please review it here before you complete this form.

Patient Agreement

By signing below, I agree that I have familiarized myself with the policies of this office and all of my questions have been answered. I acknowledge that I have received a copy of Cape Cod Dermatology, LLCs PracticePolicy Statement dated 7/1/2020 outlining practice policies, and my responsibilities relating to scheduling, canceling, and keeping timely appointments. I understand that appointments will be confirmed via phone, email, and/or text unless I have requested otherwise. I understand that Dr. Girouard and Dr.Tocci are independent contractors practicing on-site. I understand and agree that I am financially responsible for all rejected or non-covered services, and all co-pays and deductibles. I agree to access the patient portal in a secure manner. I know my rights regarding my protected health information.

Request for Payment

By signing below, I request payment of all eligible and authorized insurance benefits including but not limited to Medicare, Medicaid, Supplemental, Medigap, Commercial, and Private for me or on my behalf for any services provided by Dr. Fiske, Dr. Girouard, Dr. Tocci, or Bri Schreiner, PA-C or at Cape Cod Dermatology, LLC be paid directly to Cape Cod Dermatology, LLC.

Release of Information

By signing below, I authorize the release of any medical or other information necessary to Medicare, Medicaid, Supplemental, Medigap, Commercial, and Private Insurance and its agents any information needed to determine these benefits or benefits for related services.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Your information will be encrypted.

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