New Patient Intake - Smart Form - Cape Cod Dermatology, LLC

Contact Information

Last Name

First Name

M.I

Date of Birth

Mailing Address

Street Address

(if different)

City

State

Zip

If Patient is a Minor: Parent/Legal Guardian Names

Address if different

Primary Phone

Secondary Phone

Email address

Primary Care Physician

If none, please type none

EMERGENCY

Emergency Contact Name

Emergency Contact Phone

Insurance

1st Insurance

Member ID #

Subscriber Name

Subscriber Date of Birth

2nd Insurance

Member ID #

Subscriber Name

Subscriber Date of Birth

3rd Insurance

Member ID #

Subscriber Name

Subscriber Date of Birth

Consent 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 Tocci, or Bri Schreiner, PA-C or at Cape Cod Dermatology, LLC be paid directly to Cape Cod Dermatology, LLC.

Consent to Release 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.

Patient Name / Signature

Date

Consent to speak/share your PHI with a relative/friend

PHI is your protected health information such as your Medical Information, Biopsy results, Plan of Care, or to answer billing/insurance questions.

Name:

Relationship

Phone Number

Consent to Leave Messages

ALL appointments will be confirmed via phone, email and text unless you request otherwise.

Do you authorize detailed messages to be left/sent via text, email, voice message or answering machine with medical information such as lab/biopsy results, prescription information, or to answer a billing/insurance question?

YES I DO

NO I DO NOT

Clinical Information

What is your main reason for your new patient visit?

Please be specific

Required for Meaningful Use by The Federal Government

Occupation (before retirement if applicable)

City/State of birth

Preferred Language (please choose one or write in response)

English

Portuguese

Spanish

Other:

If other, please specify

Ethnicity (please choose one or write in response)

Latino/Hispanic

Not Latino/Hispanic

Other

Prefer Not to Say

If other, please specify

Race (please choose one or write in response):

Caucasian (White)

American Indian or Alaskan Native

Asian

Native Hawaiian or Pacific Islander

Black or African American

Prefer Not to Say

Native American

Other

If other, please specify

Pharmacy

Current Pharmacy Name and Address

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)

Other

Past Surgeries (please include dates):

Skin Disease History (Please check all that apply)

Other

If positive personal history of melanoma, please indicate date of diagnosis and treatment course:

Skin Protection (Do you wear sunscreen?)

Yes

If YES, indicate SPF here

Family Dermatology History

Do you have a family history of Melanoma?

Yes No

If yes, which relative(s)?

Do you have a family history of squamous cell carcinoma or basal cell carcinoma?

Yes No

If yes, which relative(s)?

Other Dermatology Family History (That you feel we should be aware of)

Social History

Tobacco Smoking Habits

Currently Smoke

Never Smoked

Former Smoker

Alcohol Use:

None

Less than 1 drink per day

1-2 drinks per day

3 or more drinks per day

If former Smoker, Quit on?

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

New or changing moles

New skin growths

Recent hives

Rash

Malaise

Fever or chills

Night sweats

Problems with scarring (keloids, etc.)

Immunosuppression

Other Symptoms:

ALERTS (Please check all that apply)

Vaccines

Have you had the pneumonia vaccine

Yes No

Have you had the influenza vaccine

Yes No

Have you had the COVID-19 vaccine

Yes No

If yes, Indicate date most recent vaccine

For COVID-19 vaccine, kindly check which type.

J & J

Moderna

Pfizer

Notice of Practice Policy

Please review our Practice Policy here before you sign this form

I hereby agree and acknowledge:

Financial Agreement: Patient or guarantor is financially responsible for all non-covered services, co-pays and deductibles.
Appointment and Cancellation Policy: Late arrivals may be rescheduled, missed appointments or appointments cancelled within 24 hours may be charged. Repeated missed appointments may result in dismissal from the practice.
Independent contractor: Dr. Elizabeth Tocci is directly employed and insured by Cape Cod Healthcare.
Patient Portal: An optional patient portal is available for use as a courtesy in partnership with Modernizing Medicine. Use of the patient portal is entirely voluntary and will not impact the quality of care received.
Patient Portal Safety: Patient portal is NOT for emergencies. Portal must be accessed on a secure network and password must be protected.
Privacy Policy: Cape Cod Dermatology, LLC will use and share my personal health information as outlined in the Notice of Privacy Practices printed on the Practice Policy.
Additional Rights regarding my protected health information are found on the Practice Policy.

I have read and agree to the Practice Policy

Signature

Date

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

Notes

Your information will be encrypted and forwarded to office@capecodderm.net.

Your information will be encrypted.

New Patient Intake - Smart Form

Contact Information

Insurance

Consent for Payment

Consent to Release Information

Consent to speak/share your PHI with a relative/friend

Consent to Leave Messages

Clinical Information

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)

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

Past Medical History (Please check all that apply)

Skin Disease History (Please check all that apply)

Family Dermatology History

Social History

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

ALERTS (Please check all that apply)

Vaccines

Notice of Practice Policy

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