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 Policy: We require you to confirm that your insurance is current at each office visit. New patients or existing patients with a change in their insurance information must provide a valid insurance card or temporary printout at the time of the visit. Should you be unable to provide this documentation, you may pay in full at the time of service and submit the claim to your insurance carrier for reimbursement. I understand by signing below I am responsible for notifying Calais Dermatology Associates of any changes to my insurance.

Payment Policy: Co-Payments, Co-Insurance, Deductibles, and all outstanding balances are due and collected on the day of my or my family’s appointment.

Account Balances: I am responsible for the timely payment of my account balances, coinsurance, and deductibles. All balances are due in full within 30 days of my first billing. Any balance left unpaid after 90 days, without an attempt at resolution, will be considered delinquent and may be submitted to a collection agency. If I am having financial difficulty, I will call the billing office to discuss a payment plan.

Minor patients: A legal guardian must accompany children under the age of 18 to their initial appointment so that the proper forms can be filled out & signed. Follow up visits do not require a guardian’s presence, unless a procedure is being performed that requires a signed consent form.

Appointment Cancellations: If I am unable to keep my scheduled appointment, I will call Calais Dermatology to cancel or reschedule my appointment. All regular and cosmetic appointments require 24-hour cancellation notice. Deposits for Cosmetic appointments are nonrefundable in the event the appointment is not cancelled 24-hours in advance. Surgical appointments require 48-hour cancellation notice. After 3 no-show appointments without providing proper 24 hours' advance notice, I will be dismissed from Calais Dermatology. Please not this courtesy makes it possible to give your reserved time to another patient who may really need it.

Skin Biopsies: Calais sends all skin biopsies to Sagis Labs. Sagis provides us with comprehensive diagnostic and prognostic information so we can accurately diagnose the disease, prescribe effective therapies, and initiate early treatment options. If you would like your labs to be sent to a different lab, it is your responsibility to let the nurse know at the time of your visit.

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.