Oahu Dermatology LLC-Intake and History Form

Dr. Carla Nip-Sakamoto, M.D., Dr. Miki Garcia, M.D., Dr. Summer Chong, M.D.

Please correct the errors described below.

Past Medical History

Past Surgical History

Skin Disease History

Allergies

Social History

Review of Systems (pertaining to yourself)

Please select YES or NO if you have experienced any of the following within the last 30 days:

Alerts

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