New Patient Form

PERSONAL INFORMATION

Last Name

First Name

Middle

DOB

Age

Sex

Height

Weight

Race

Marital Status

CONTACT INFORMATION

Mailing Address

City

State

Zip

Home

Cell

Work

Email address

Preferred Contact Method

Home Cell Email

Emergency Contact Name

Number

PCP/ Referring Doctor Name

Number

Preferred Pharmacy

INSURANCE INFORMATION

Primary Insurance

Policy ID

Group #

Secondary Insurance

Policy ID

Group #

Employer Name

Relationship of patient to the insured

I authorize the release of medial information to my primary care or referring physicians, to consultants if needed and necessary to process insurance claims, insurance applications, and prescriptions. I also authorize payments of medical benefits to the provider.

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/Guardian Signature

Date

History and Intake Form

What is the nature of your visit?

Past Medical History: (please check all that apply)

Other

Past Surgical History: (please check all that apply)

Other

Skin Disease History: (please check all that apply)

Other

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? *excluding Basal and Squamous Cell Carcinoma*

Yes No

If yes, which relative(s)?

Have you received your Flu Shot this year?

Yes No

Have you received a Pneumonia shot in the past?

Yes No

Medications: (Please enter all current medications and dosage)

Drug Allergies: (Please enter all allergies)

Social History: (Please check all that apply)

Do you consume alcohol? (EtOH or grain alcohol)

Yes No

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

Do you smoke?

Yes No

Advance Care Planning:

Do you have a health care proxy in the event you are unable to make your own medical decisions?

Yes No

Designee’s Name:

Designee’s Phone Number:

Family Medical History: (Mother, Father, Brother, Sister, or Child) indicate with 1st letter.

Ex: Mother has heart disease M

Heart Disease

Hypertension

Cancer

Diabetes

Stroke

Other

Calais Dermatology Associates Office Policy

Insurance Card(s): I understand that I am required to provide a valid insurance card at check-in for my visit. It is my responsibility to notify Calais Dermatology of any updates or changes to my insurance. If I am unable to provide a valid insurance card, I understand that I will need to reschedule my appointment until I can provide the necessary documentation.
Payment Policy: I acknowledge that all co-payments and outstanding balances, that may include co-insurance and deductibles, are required to be collected at check in. I understand all cosmetic treatments must be paid for at the time of service.
Account Balance: I am responsible for the timely payment of my account balance. If my balance remains unpaid after three statements have been sent, further action may be taken to resolve the balance.
Limited Benefit Plans: Our office does not contract with Limited Benefit Plans (LBPs). These plans provide coverage for specific services or conditions with predetermined monetary caps. If you have an LBP, you will be treated as a self-pay patient. We will provide the necessary information for you to submit to your LBP for potential reimbursement.
Skin Biopsies: I understand that skin biopsies are sent to Sagis, SkinDX, or Borsting laboratories for analysis. These labs have been selected based on their ability to provide comprehensive diagnostic and prognostic information, which is essential for accurate disease diagnosis, prescribing effective therapies, and determining initial early treatment options. I understand it is my responsibility to inform Calais Dermatology if I prefer my skin biopsy to a different lab due to my insurance coverage.
Appointment Cancellation and No-Show Policy: We value your time and strive to provide the best care possible. To offer appointments to all our patients, we ask for your cooperation with the following cancellation and no-show policy.
1. We require 24 hours advance notice for the cancellation or rescheduling of any appointment. This allows us to accommodate other patients who may need care.
2. If you do not show up for your scheduled appointment without providing the required 24-hour notice, you will be charged a $50 no-show fee for all medical appointments, and a $100 no show fee for all cosmetic appointments.
Return Policy: At Calais Dermatology, we strive to provide the highest quality care and products for our patients. To ensure the safety and integrity of all products, please note that all medications and products purchased at Calais Dermatology are nonreturnable.
NSF Checks: I understand that if I issue a check that is returned for insufficient funds, I will be charged a $75 NSF fee. I will make alternative payment arrangements if necessary.
Minor Patients: A legal guardian must accompany children under the age of 18 to all appointments.

I have read and fully understand Calais Dermatology’s office policy and acknowledge my responsibilities as outlined within.

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/Guardian Signature

Date

By signing this form, I understand and agree to abide by Calais Dermatology Associates office policies on this form.

Calais Dermatology Associates HIPAA Policy

Patients over the age of 18 are protected under the Federal Health Insurance Portability and Accountability Act. This Federal Law prohibits any staff member of Calais Dermatology from discussing appointments, medication, test results or treatment plans with anyone other than the patient. If you would like to permit someone to discuss your medical condition, confirm appointments or obtain results for you, please indicate their name(s) below.

Add individual

I understand only the individuals listed above will be provided with information. Should I wish to change or delete any of the names listed above, I will contact Calais Dermatology and request a Patient Update form.

Patient/Guardian Signature

Date

Calais Dermatology Associates Notice of Privacy Practices Patient Acknowledgement

I received and understood Calais Dermatology Associate’s Notice of Privacy Practices written in plain language. This notice provides detail on how Medical Information about you may be used and disclosed and how you can get access to this information. I understand that this practice reserves the right to change the terms of its Notice of Privacy Practices. If changes to the policy occur, this practice will provide me with a revised Notice of Privacy Practices upon request.

Patient/Guardian Signature

Date

Your information will be encrypted.