New Patient Forms

BEACON SKIN AND SURGERIES

Please do not add any special characters when filling out form.

Client Information

First Name:

Last Name

Date of Birth:

Address:

City:

State

Zip Code:

Gender:

Primary Number:

Secondary Number:

Email Address:

Emergency Contact Name and Relation

Emergency Contact Phone #

Preferred pharmacy:

Referring Physician

Please include Phone number and Address

Primary Care Physician

Please include Phone number and Address

Primary Insurance

Name of Insurance

Policy Type:

Member ID #:

Group #:

Secondary Insurance

Name of Insurance

Policy Type

Member ID #

Group #

Who referred you to our office or how did you hear of us?

Please list the name, phone number and fax of any doctor who should receive a note a bout today's visit

Medical History

Please list any prior surgeries or procedures

Don't forget any heart, joint,skin surgeries, C-section, tubal ligation, or hysterectomy

Please list the medications you are taking

Do you have any allergies to medications?

MIPS

Have you had a Flu Shot?

Yes

Have you had the Pneumonia Vaccination this year?

Yes

Do you have a living will? Please state who the surrogate is, if yes

Yes

How often do you exercise?

What is your caffeine intake?

Female Patients Only ( 10 years and older)

When was the last day of your last period?

If yes, which method are you using?

i.e. birth control, IUD, abstinence, condoms

If yes, what SPF?

Family History

If yes, which relative?

General Questions

Date field

Your information will be encrypted.

New Patient Forms

BEACON SKIN AND SURGERIES

Client Information

Primary Insurance

Secondary Insurance

Medical History

MIPS

Female Patients Only ( 10 years and older)

Family History

General Questions

BEACON SKIN AND SURGERIES

Beacon Skin and Surgeries