New Patient Form

Patient Information

Last Name

First Name

Middle Name

Social Security Number

Mailing Address

Apt

City

State

Zip

Date of Birth

Gender

Male Female

Home Phone

Cell Phone

Work Phone

Ethnicity

Hispanic Non Hispanic

Preferred Language

2nd Seasonal Address

Apt

City

State

Zip

Preferred Pharmacy

Phone

City

PERSON RESPONSIBLE FOR CHARGES

IF PERSON RESPONSIBLE FOR PAYMENTS IS DIFFERENT FROM PATIENT THEN PLEASE COMPLETE THE FOLLOWING:

IF PATIENT IS A CHILD, PLEASE INDICATE IF PARENTS ARE:

Single Married Divorced

Full name

Mailing Address

Apt

City

State

Zip

Social Security Number

Date of Birth

Preferred Phone Number

Alternate Phone Number

EMERGENCY CONTACT INFORMATION

In case of emergency please notify

Phone Number:

MEDICAL RECORD DISCLOSURE

I authorize Eyre Dermatology Clinic to discuss the following aspects of my care with the following individual(s):

Add another authorize person

INSURANCE INFORMATION

PLEASE PROVIDE A COPY OF THE CARD TO THE RECEPTIONIST

Primary Insurance

Insurance Name

Policy / ID #

Group / Account #

Policy Holder's Name

Date of Birth

Relationship to Patient

Secondary Insurance

Insurance Name

Policy / ID #

Group / Account #

Policy Holder's Name

Date of Birth

Relationship to Patient

OTHER FAMILY MEMBERS SEEN

Add Family Members

PAST MEDICAL HISTORY

Other

PAST SURGICAL HISTORY

Other

SKIN DISEASE HISTORY

If Other, please specify

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

It is ok to have my current medication list transferred from the pharmacy

Yes No

No Medication

Please list all current prescription medications

Add another medication

MEDICATION ALLERGIES

List Medication Allergies

No Medication

Add another medication allergy

SOCIAL HISTORY

Smoking Habits

Never smoker Current everyday smoker Current someday smoker former smoker

Alcohol Intake

None Less than 1 drink per day 1-2 drinks per day 3 or more drinks per day

How many times in the past year have you had 5 or more drinks in a day for men, or 4 or more drinks in a day for women?

ARE YOU CURRENTLY EXPERIENCING ANY OF THE FOLLOWING

If Other, please specify

ALERTS

If others, please specify

REASON FOR SEEING THE PHYSICIAN TODAY

FINANCIAL, TREATMENT AND HIPAA CONSENT

I understand that while Eyre Dermatology Clinic contracts with many insurance companies, it is MY responsibility to verify with my insurance plan that the physician I am seeing is a participating provider. I further understand that Eyre Dermatology Clinic will bill my insurance as a courtesy to me. If, however, my insurance does not cover the services, I will be financially responsible for the services rendered. All procedures performed have a charge associated with them unless specifically discussed beforehand with the physician. I hereby authorize Eyre Dermatology Clinic to submit insurance claim forms along with medical records necessary to obtain payment from my insurance company. I understand that I am responsible for all charges regardless of insurance coverage. It is my responsibility to provide Eyre Dermatology Clinic with correct and current information. Failure to do so will limit the ability to bill insurance for payment. I understand that co-pays are due at the time of service. We cannot “split bill” divorced or separated parents. It is the responsibility of the parent that signs this form and/or brings the child in for treatment to make payment in full to Eyre Dermatology.

Blood tests and pathology consults are not billed from Eyre Dermatology Clinic and are sent at the discretion of the physician. You will receive a separate bill from these facilities. These facilities will bill your insurance for tests ordered. You may still receive a bill for deductibles and co-pays as required by your insurance. By signing this, I authorize Eyre Dermatology Clinic to provide these facilities with the necessary information to process claims on my behalf.

If my account becomes more than 90 days past due, the account will automatically be turned over to a collections agency, and additional charges will be assessed.

By supplying my home phone number, mobile phone number, email address and any other personal contact information, I authorize Eyre Dermatology to employ a third party automated outreach and messaging system to use my information, the name of my care provider, the time and place of my scheduled appointment(s), and other limited information, for the purpose of notifying me of a pending appointment, a missed appointment, overdue wellness exam, balances due, lab results or any other healthcare related functions. I also authorized Eyre Dermatology to disclose to third parties, who may intercept these messages, limited protected health information regarding my healthcare events. I consent to receiving multiple messages per day when necessary. I consent to allowing detailed messages being left on my voicemail or with another person if I am unavailable at the number provided by me.

I acknowledge that photos taken are used to assist in patient recognition per HIPAA guidelines. I authorize the doctor to release any medical information including diagnosis, test results, reports, and records pertaining to any treatment or examination rendered to me. I understand that any person(s) that receive these medical records will not release any of the medical information obtained by this authorization to any other person or organization without a further authorization signed by me for release of information. I authorize payment of medical benefits to Eyre Dermatology Clinic and physicians. I have received a copy of the HIPAA policy. I authorize treatment.

Patient or Responsible Party Signature

Date:

If signing on behalf of a Minor, please state Relationship

Print Name

Your information will be encrypted.