If Yes, Please give the benefits card to the patient service representative when you check-in
Have you been previously diagnosed with any of the following? (Check all that apply or None )
Skin Disease History: (Check all that apply or check none.)
List all medications you are currently taking. Include prescriptions over the counter medications, vitamins, and herbals. Use additional paper if needed. Please notify our office if you decline to have your medication list imported from participating pharmacies.
PLEASE GIVE YOUR PHARMACY INSURANCE CARD TO THE FRONT OFFICE AT CHECK IN TO HELP FACILITATE YOUR MEDICATIONS ARE AUTHORIZED PROPERLY.
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