New Patient Form

PATIENT INFORMATION

Date

Social Security #

Date of Birth

Last Name

First Name

Middle Initial

Home Phone

Cell Phone

Mailing Address

City

State

Zip

2nd Address

City

State

Zip

Employer

Work Phone

Sex

M F

Marital Status

Minor Single Married Divorced Widow Separated

Preferred Language:

Race:

Ethnic Group: Hispanic

Yes No

Referral Information, Patient Financial Policy and Signature On File

Other family members that are patients

Primary Care Physician

Phone

Insurance Information (Please Give Insurance Cards and Photo ID to Receptionist to Copy)

Insured Name

Relationship to Patient

Insured Birthdate

Insured Social Security #

Insured Employed By

Work Phone

Primary Insurance Name

Insurance Provider Billing Address

Policy #

Group #

Add Secondary Insurance

How Did You Hear About Us?

Select One

Doctor Family Friend Internet Webpage Facebook Twitter Magazine Other

If Other, Please Describe:

Do You Give Our Office Permission To Discuss Your Medical Information With Any One Else?

Yes No

If yes, please provide their names and phone numbers below.

Add new row

May we leave personal medical information on your answering machine or cell phone?

Yes No

May we text reminders and personal medical information to you?

Yes No

May we e-mail personal medical information to you?

Yes No

E-mail Address

Receipt Of Notice Of Privacy Practices

My signature below indicates that I have received and/or reviewed a copy of Lakeside Dermatology’s Notice of Uses and Disclosures of Protected Medical Information (Notice of Privacy Practices).

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

Patient or Responsible Party Signature

Date

Payment Policy

Self-Pay Patients - I understand that I am required to pay 100% of the total bill at the time of service.

Insured Patients - I understand that I will be responsible for paying my deductible, co-payment, co-insurance, and charges for any non-covered and/or cosmetic services.

Laboratory Services - I understand that if I have a skin biopsy and/or any other laboratory services performed, it will be sent to an outside laboratory to be tested and I may receive a bill from the laboratory (for example: Ameripath, IRL, Quest, LabCorp, etc.) and it is my responsibility to inform Lakeside Dermatology, LLC staff if my insurance requires a particular laboratory.

Cancellation Policy-I understand that if I fail to give 48 business hours’ notice to cancel or reschedule my appointment, that I will be required to pay a $150 Surgical Appointment or $50 Dermatologic Appointment fee.

Patient or Responsible Party Signature

Date

Assignment and Release

I hereby authorize payment directly to Michael J. Rogers, MD and Lakeside Dermatology, LLC for all insurance benefits otherwise payable to me for services rendered. I understand that I am financially responsible for all charges, whether or not paid by insurance, and for all services rendered on my behalf or my dependents. I authorize the above doctor and/or any provider or supplier of services in Lakeside Dermatology to release the information required to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.

Patient or Responsible Party Signature

Date

PATIENT MEDICAL HISTORY

Past Medical History

Diabetes

Type

If Other, Please List:

Past Surgical History

If Other, Please List:

Skin Disease History

If Other, Please List:

Pharmacy Information

(This will be the pharmacy where all of your prescriptions will be sent)

Pharmacy Name

Location

Phone Number

Medications

Please list all current prescription and/or OTC medications

Name (Ex: Aspirin)

Strength (Ex: 81mg)

Dose (Ex: 1 tablet)

Frequency (Ex: at night)

Add Another Medication

Allergies

Please list all allergies

Social History

Smoking Use

Currently Smokes

How many packs per day?

Former Smoker

How long ago did you stop?

Total Years Smoked

Neve Smoked

Alcohol Use

None Less than 1 drink per day 1-2 drinks per day 3 or more drinks per day

Drug Use

Currently Use Formerly Used Never Used Drugs IV Drug Use?

Currently Used Drugs

Formally Used Drugs

Do you have a living will?

YES NO

Family Medical History

Please only list first degree relatives and their history

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