Patient Information Form

Please correct the errors described below.

IF MAILING ADDRESS IS A POST OFFICE BOX - PLEASE GIVE PHYSICAL ADDRESS

I hereby give my permission to disclose personal information about my treatment to the following individuals:
(Example: Spouse, parent/legal guardian, friend, etc.) We may only give information to listed individuals (including
parents & spouses). If no one is listed Access Dermatology CANNOT give any information about you.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Consent to Leave Messages

Acknowledgment of Notice of Privacy Practices

I have read and agree to the Notice of Privacy Practices provided to me by Access Dermatology, PC.

Acknowledgment of Financial Policy

I have read and agree to the Financial Policy provided to me by Access Dermatology, PC.

Authorization and Consent to Treat

I, the undersigned, authorize Mary Mather, MD to provide medical care to me or my minor dependent. I, the undersigned, authorize
release of any medical information or other information necessary to process insurance claims for myself or my minor dependent. I,
the undersigned, request that payment of authorized Medicare and/or other insurance benefits be made, for me or on my behalf, to
Access Dermatology, PC, for any services furnished by that physician/provider. I authorize any holder of medical information about
me to release to my insurance carrier and/or the Center for Medicare and Medicaid Services and its agents any information needed
to determine these benefits are payable for related services.

History and Medical Intake Form

Past Medical History

If you checked the following conditions from above, please indicate the YEAR.

Past Surgical History

Please check all that apply, or check NONE.

Medications

Social History

Please select all that apply.

Skin Disease History

If you checked the following skin diseases above, please indicate YEAR, and WHERE (which part of the body).

Family History

Please list affected first degree relative: Mom, Dad, Sister, and Brother. Indicate if NONE.

For Female Patients

Your information will be encrypted.

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