Patient Registration

Entire form must be completed

Today’s Date:

Referred to us by:

How Did You Hear About Our Office?

Internet

Physician

Friend/Relative

Facebook

Yellow Pages

If Other, please specify:

Patient’s First Name:

Last Name:

Date of Birth:

Mailing Address:

City:

State:

Zip:

Social Security #:

Responsible Party if patient is a child:

Address if different:

Home Phone:

Cell Phone:

Alternate Number:

Name and Location of Pharmacy: Your prescriptions will be sent electronically to this location.

Name of Pharmacy:

Location of Pharmacy:

Email Address:

Emergency Contact Name:

Emergency Contact Number:

APPOINTMENT REMINDERS: (PLEASE CHOOSE ONE)

TEXT TO CELL PHONE NUMBER LISTED ABOVE EMAIL SENT TO EMAIL ADDRESS LISTED ABOVE

PRIMARY INSURANCE (please give your insurance card to the receptionist)

Primary Insurance:

Policy Holder’s Name:

Policy ID Number

Policy Holder’s SSN:

Policy Holder’s DOB:

Patient’s Relation to Card Holder:

Self Spouse Child

If Medicare Patient, are you currently employed:

Yes No

Disabled:

Yes No

End Stage Renal Disease:

Yes No

SECONDARY INSURANCE (please give your insurance card to the receptionist)

Secondary Insurance:

Policy Holder’s Name:

Policy ID Number

Policy Holder’s Social Security:

Policy Holder’s DOB:

My signature below acknowledges that I understand the following:

Co-pays and deductibles will be collected at the time of service. I am responsible for timely payment of any balance.
Payment for cosmetic procedures and products are due at the time of service.
I authorize the medical providers to evaluate and treat my medical condition. I authorize the release of medical information as needed to my referring physician, consultants and insurance carrier to process insurance claims, applications and prescriptions. I also authorize payment of medical benefits to the physician.
There may be an additional charge from an outside laboratory for pathology services if a biopsy is performed.

Patient consent and Acknowledgement of Privacy Policy:

I acknowledge, understand and have been given a copy of the HIPAA Notice of Privacy Practices. HIPAA does permit sharing of information with friends/family unless the patient objects to such disclosure. Please indicate if there is any individual you DO NOT WANT your Personal Health Information shared with. For example: appointment reminders, medical condition or results of biopsy/tests.

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/Responsible Party Name:

Date:

Patient Medical History

It is necessary to have this information in order to provide you with the highest quality medical care.

Past Medical History:

If Other, please specify:

Past Surgical History:

If Other, please specify:

If Mastectomy is selected, please specify:

Right Left Bilateral

If Lumpectomy is selected, please specify which part:

Right Left Bilateral

If Knee Replacement is selected, please specify which part:

Right Left Bilateral

If Hip Replacement, please specify which part:

Right Left Bilateral

If Kidney Removed is selected, please specify which part:

Right Left Bilateral

If Testicles Removed is selected, please specify which part:

Right

Left

Bilateral

Skin Disease History:

If Other, please specify:

Do you wear Sunscreen?

Y N

Do you tan in a tanning salon?

Y N

Do you have a family history of Melanoma?

Y N

If yes, how are you related?

Social History:

Please select:

Never Smoked Quit: Former Smoker Smokes less than daily Smokes daily

Alcohol Use:

Please select:

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

No Changes in my medical history since last visit

Medications: (Please list)

None

No changes since last visit.

Name and Strength:

Dosage:

How often do you take it:

Add new medication

Drug Allergies: (Please list)

Add another allergy

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:

Date:

Your information will be encrypted.