New Patient Form

Welcome to Booth Dermatology and Cosmetic Center! Thank you for choosing us for your dermatological needs. Please note, if a patient is under 18 years of age, a parent or guardian must complete paperwork and attend the appointment with the minor. We are required to update your paperwork EVERY YEAR, by law, regardless of whether anything has changed. We appreciate your cooperation with this matter. Please read over these forms carefully and take your time filling them out fully and legibly.

Last Name

First Name

Middle Initial

Gender

DOB

Occupation

Employer

Address

City

State

Zip Code

Primary Phone Number

Secondary Phone Number

Is it OK to leave a detailed message on either of your phone numbers? (Select one)

Yes No

Email Address

By providing your email address you are authorizing the office to contact you via email.

Social Security Number

Emergency Contact Name and Number

Preferred Pharmacy Name and Phone Number

Primary Care Physician

Referring Physician

Flu Vaccine this year?

Do you have a CoPay?

Reason for Visit

For patients over the age of 65:

Have you had a Pneumonia Vaccine?

Yes No

Have you had a Influenza Vaccine?

Yes No

Do you have a healthcare proxy in the event that you’re unable to make your own medical decisions?

Yes No

Designee’s Name:

Designee’s Phone #:

Do you have a living will?

Yes No

Which statement best reflects your wishes regarding advanced care recommendations?

Do not intubate Do not resuscitate Full resuscitation

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?

Yes No

If yes, which relative(s)?

Medications: (Please list all current medications)

Add Medication

Allergies: (Please list all allergies)

Please list any medical conditions of immediate relatives:

Alerts: Please check all that apply

Allergy to adhesive or lidocaine?

Pregnant or trying to become pregnant?

Artificial joint replacement

Allergy to topical antibiotics?

Pacemaker or defibrillator?

Artificial heart valve?

I give permission for you to share my medical information, including but not limited to appointment times & pathology reports with the following people:

Add Person

If you wish to hear about services other than what we’ve already provided for you, please let us know! Check all that apply & we’d love to speak with you about them!

Booth Dermatology Patient Questionnaire

Patient Name

Date

Other than the other service we have already provided for you, what additional services would you like to learn about? Please check all that apply!

Booth Dermatology Office and Financial Policies

We make every effort to submit your claims to your insurance company in a timely manner. However, if your statement is returned to our office due to an incorrect address, we will make only one further attempt to contact you via the phone number you’ve provided us.

Consent to Treat: I request and give consent to Booth Dermatology Group, PC, its agents, employees, physicians, associates, who may attend to me to provide and perform such medical/surgical care, tests, procedures, drugs, and other services and supplies as are considered necessary or beneficial by my practitioner for my health and well-being. I acknowledge that no representations; warranties, or guarantees as to the results or cures have been made to me.

Release of Medical Information: I hereby give my consent to Booth Dermatology and/or the physician/practitioner’s employee by Booth Dermatology, to provide requested information from my medical record to third party payers and/or other healthcare providers as deemed necessary.

Medicare Patients: I certify that the information given by me in applying for payment under the Social Security Act is correct. I authorize Booth Dermatology, PC to release information from my medical record to the Social Security Administration and/or Medicare program or its intermediaries or carriers or the Professional Standards Review Organization for processing of claims for medical benefits. I request that the payment of authorized benefits be made on my behalf to Booth Dermatology, PC.

Pre-certification: Your insurance company may require a pre-certification, prior authorization, or referral for services such as but not limited to surgery, prescriptions, or services provided at places other than in our facility. It is the patient’s responsibility to ensure these have been obtained prior to services being rendered.

Financial Agreement: All payments, deductibles, co-pays, and non-covered services are due at the time of service. We accept cash, personal checks, credit cards, and CareCredit. Self-pay patients, (those not covered by ANY insurance policy or third party payer) are required to pay for services PRIOR to being seen by the provider. The undersigned guarantees payment of the account in full, and agrees to pay the account if a private or governmental insurance carrier does not pay such account. It is the patient’s responsibility to make sure insurance payments are processed and paid promptly to Booth Dermatology, PC; as well as understanding what services are covered under their medical insurance policy. If the amounts due to Booth Dermatology, PC for services rendered become delinquent & the debt is referred to an attorney and/or third party for collections, it is understood and agreed that Booth Dermatology, PC shall recover all costs and expenses incurred in the collection of any such delinquent amount. This includes legal interest on the balance due, together with any collection costs & reasonable attorney fees.

Worker’s Compensation: If you are being seen due to work related injury or illness, we will need appropriate documentation from your employer to file a worker’s compensation claim. Without this information the claim will be your responsibility.

Cancellation Policy: Our office is very busy and Dr. Booth is committed to giving patients her undivided attention and the best care possible. Please let us know as soon as possible if you are not going to be able to make your appointment, and always schedule your follow-up appointments before you leave the office. If you are scheduled for a cosmetic procedure that is not deemed medically necessary by your insurance provider, our office requires that you pay for 50% of the procedure at least one week in advance from the date of your procedure. If you need to cancel your appointment, please let our office know at least 2 business days before your appointment. Failure to advise our office will result in a cancellation fee of $25 to be charged to your account.

Returns/Refunds: If you purchase a package of treatments from our office, and decide at later date that you no longer wish to use these services, you may transfer the amount paid towards another service at Dr. Booth’s discretion. If a single service from your package has already been redeemed, the full price amount of that single service will be deducted from the amount that is being transferred. A product may be returned to our office if it has been unopened, within 30 days of purchasing the product.

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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