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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