Cape Cod Dermatology, LLC - New Patient Intake

Contact Information

MRN (Medical Record Number)

If you do not have this number please call us for this information

Last Name

First Name

M.I

Date of Birth

Mailing Address

Street Address

(if different)

City

State

Zip

Home Phone

Cell Phone

Work Phone

Email Address

Emergency Contact Name

Emergency Contact Home Phone

Emergency Contact Cell Phone

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

If Minor: Parent/Legal Guardian Names

Responsible Party (if not self)

Primary Care Physician

If none please type 'none'

What is your main reason for today’s visit?

Insurance

1st Insurance

Member ID #

Subscriber

Date of Birth

2nd Insurance

Member ID #

Subscriber

Date of Birth

3rd Insurance

Member ID #

Subscriber

Date of Birth

Messages

I authorize messages via text, email, voice message or answering machine with medical information such as lab/biopsy results, prescription information, or billing/insurance.

YES I DO

NO I DO NOT

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.

Name:

Relationship

Phone Number

Required for Meaningful Use by The Federal Government

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 awareof)

Social History

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

If yes, Indicate date most recent vaccine

Practice Policy Agreement

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

I have read and agree to the Practice Policy Agreement

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.

Patient Name / Signature

Date

Short text

Your information will be encrypted.

Cape Cod Dermatology, LLC - New Patient Intake

Contact Information

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

Insurance

Messages

Communication Permission

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

Practice Policy Agreement

Patient Agreement

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