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

Please correct the errors described below.

Contact 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

Consent to Leave Messages

Consent to Communicate with a Relative/Friend

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 Consents

Privacy Practices

Please review our Notice of Privacy Practices here before you sign this form.

I acknowledge that I have received a copy of Cape Cod Dermatology, LLC privacy practices.

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.

Practice Policy Statement

Please review our Practice Policy Statement here before you sign this form.

I acknowledge that I have received a copy of Cape Cod Dermatology, LLCs Practice Policy Statement dated 6/15/2022 outlining practice policies and my responsibilities relating to scheduling, cancelling 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 agree with the policies of this office and all of my questions have been answered.

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.

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. Girouard, 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.

Your information will be encrypted.

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