Patient Intake Form

Date:

Patient's Name

Birthdate

Height

Weight

Pharmacy

Doctor

Smoking status

Smoker Non smoker

Do you have someone with you today at visit today?

Yes No

If yes, who is with you?

Have you seen another Dermatologist? (Since your last appointment here)

Yes No

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Have you been hospitalized? (Since your last appointment here)

Yes No

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Have you had medical testing done? (Since your last appointment here)

Yes No

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What areas of concern do you have for today’s appointment (indicate on diagram & explain)?

Add new row

Blood pressure:

Pulse:

Body Temperature:

Pulse Oximetry:

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.

Signature of Patient, Parent, or Legal Guardian

Relationship to Patient

Date

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Patient Intake Form

PATRICK WEGMAN, M.D

DERMATOLOGY, HEALTHY SKIN FOR A LIFETIME