DR. DUBOW PATIENT INTAKE

Name

Date of Birth

Social Security Number

Driver’s License: Number

State

Legal Guardian or responsible party (if different from above)

Home Address: Street

City

State

Zip

Billing Address (If different)

C/O

Street

City

State

Zip

Employer

Occupation

Home Phone

Mobile

Office

Please mark (check box) which of the above numbers is your preferred contact to reach you, confirm appointments or leave messages.

Email Address

Do we have your consent to communicate with you by e mail regarding lab results, prescription refills or other non urgent matters?

Yes No

Emergency Contact

Name

Telephone

Relationship

How did you hear about our office?

Referred by another physician

Name

Referred by another patient

Name

Referred by affiliated industry (facialist/hair salon, etc.)

Internet Search

Google

Yelp

Other

If other, please specify.

Insurance Directory (which company?)

Other

If other, please specify

MEDICAL HISTORY

Do you have any history of:

Artificial Joints?

Yes No

Heart Disease?

Yes No

Liver Disease/Hepatitis?

Yes No

Bleeding Problems?

Yes No

Difficulty Healing Wounds?

Yes No

Depression/Anxiety or Bipolar Disorder?

Yes No

Fever Blisters?

Yes No

Thyroid Disease?

Yes No

Immune Deficiency/HIV?

Yes No

Family History of Skin Disease or Skin Cancer? (If yes, explain below)

Yes No

Heart Murmur?

Yes No

Artificial Heart Valve?

Yes No

Pacemaker?

Yes No

High Blood Pressure?

Yes No

Diabetes?

Yes No

Diabetes Type

T1 T2

Non skin Cancer? (Explain below)

Yes No

Rheumatic Fever?

Yes No

Keloids?

Yes No

Kidney Disease?

Yes No

Blood Clots?

Yes No

Glaucoma?

Yes No

Require Antibiotics before medical/dental Procedures?

Yes No

If yes, why?

Allergy or sensitivity to anesthetic agents?

Yes No

Prior Cosmetic Procedures?

Yes No

If yes, please specify:

Additional information for “yes” answers

CURRENT MEDICATION/DRUG ALLERGIES: include dietary supplements, aspirin, and birth control pills

Current Medication/Dosage

Add Current Medication/Dosage

Drug Allergies

Add Drug Allergies

Other Medications

DERMATOLOGIC HISTORY

1. Is there a history of melanoma in your immediate family?

Yes No

If yes, who?

2. Do you have a history of severe sunburn(s) as a child or a teen?

Yes No

3. Do you regularly sunbathe or visit tanning salons?

Yes No

4. Do you regularly apply sunblock to exposed areas?

Yes No

If yes which SPF?

Do you or anyone in your family have a history of any skin disease? (rashes, eczema, psoriasis, etc.)

Yes No

If yes, please explain

TODAY’S VISIT

What is the primary reason for your visit today?

Changing Mole/Skin Growth

Full Body Check/Skin Cancer Screening

Other

Acne

Rash

Hair Loss

Cosmetic: (check all that apply)

Botox

Filler

Laser Rosacea or Spider Veins

Laser Freckles

Laser Tattoo Removal

Laser for fine lines / skin laxity

Other

PHARMACY INFORMATION — PROVIDE ALL INFORMATION FOR PRESCRIPTIONS TO BE FILLED

Pharmacy Name

Address (or intersection)

Phone

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 Signature

Date

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