History and Intake Form 2019

Please correct the errors described below.

I understand and agree that, (regardless of insurance status), I am ultimately responsible for the balance on my account for any professional services rendered. All court fees, attorneys fees or other fees necessary to collect this account are payable by me. I have read all the information on this sheet and have completed the above answers. I certify this information is true and correct to the best of my knowledge. I will notify you of any changes in my health status or the above information.

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.

WE WILL ACCEPT ASSIGNMENT WITH MEDICARE ON SERVICES RENDERED TO MEDICARE PATIENTS. ALL MEDICARE PATIENTS WILL BE RESPONSIBLE AT THE TIME OF VISIT FOR THEIR 20% AND ANY PART OF THEIR DEDUCTIBLE THAT HAS NOT BEEN MET.

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Past Medical History

Please check all that apply

Past Surgical History

Please check all that apply

Skin Disease History

Please check all that apply

Family Medical History

please check all that apply

Medications: (Please list all current medications)

Add New Medicaiton

Allergies: Please enter all allergies

Add allergy

Social History

Please check all that apply

Review of Systems: Are you currently experiencing any of the following?

(Please check Yes of No for the following symptoms)

Alerts: Are you currently experiencing any of the following? (please check all that apply)

Pharmacy

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