INTAKE FORM

Acclaim Dermatology, PLLC

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Alerts: Please Check YES or NO

*Women only

Past Medical History: (please check all that apply)

Past Surgical History: (Please Check all that apply)

Skin Disease History: (please check or circle all that apply)

Social History: (Please check all that apply)

In Case of Emergency

The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Acclaim Dermatology or insurance company to release any information required to process my claims.

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