New Patient Forms

Patient Registration Form

Patient First Name

Last Name

Date

Preferred to be called

Title

Mr. Ms. Mrs. Miss Dr.

Sex

Male Female

Birthdate

Age

Social Security Number

Home Address

City

State

Zip

Home Phone #

Cell Phone #

Work Phone #

Preferred Contact

Home Cell Work

Where should the statement of account be sent if different from above:

Name

Address

City

State

Zip

Card Holder Name

Social Security #

Card Holder Birthdate

Employer

Do you have prescription coverage?

Yes No

Primary Care Physician

Phone Number

Who referred you to this office?

Physician Relative Friend Co-worker

If etc, please indicate

Name

In case of emergency contact

Please present insurance cards and photo ID to medical receptionist so copies can be made.

Do we have permission to:

Leave a message on your answering machine at home?

Yes No

Leave a message at your place of employment?

Yes No

Discuss your medical condition with any member of your household?

Yes No

If yes, whom:

Relationship

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.

Patient Signature

Date

Medical History Form

Name

Date of Birth

Name of primary care physician (if you have one)

What brought you to the office today? (please check apppropriate box)

Routine skin check

Change in a mole

Rash

Acne

Wart

Other

If other, please explain

List all medications you currently take

Personal History

Illnesses: Have you ever had (please check all that apply)

Skin Cancer

Yes No

Chicken Pox

Yes No

Rheumatic Fever

Yes No

Heart Disease

Yes No

Arthritis and rheumatism

Yes No

Any bone or joint disease

Yes

Raynaud's Syndrome

Yes No

Gonorrhea or syphilis

Yes No

Jaundice or hepatitis

Yes No

AIDS or HIV positive

Yes No

Tuberculosis

Yes No

Diabetes

Yes No

High or low blood pressure

Yes No

Colitis or other bowel disease

Yes No

Hay fever or asthma

Yes No

Hives or eczema or psoriasis

Yes No

Frequent infections or boils

Yes No

Other Cancer

Yes No

If yes, what type?

Other cancer

Have you ever been advised to take an antibiotic before a procedure such as dental work?

Yes No

Do you take aspirin or aspirin containing products on a regular basis?

Yes No

Have you ever had a bleeding disorder?

Yes No

Allergies

Are you allergic?

Aspirin

Yes No

Codeine

Yes No

Betadine

Yes No

Lidocaine

Yes No

Penicillin

Yes No

Sulfa

Yes No

Mycins/other antibiotic

Yes No

Merthiolate (Mercurochrome)

Yes No

Other drugs

Yes No

Please indicate other drugs

Foods

Yes No

Please indicate foods

Adhesive tape

Yes No

Nail polish/other cosmetics

Yes No

Tetanus Antitoxin or serums

Yes No

Have you ever had a blood or plasma transfusion

Yes No

Have you had surgery

Yes No

Do you have symptoms of

Joint paint

Yes No

Swelling of any joints

Yes No

Redness or heat of any joint

Yes No

Growth in neck or throat

Yes No

Brittleness of nails

Yes No

Dryness of skin

Yes No

Easy bruising

Yes No

Inability to stand heat

Yes No

Inability to stand cold

Yes No

Change in hair texture

Yes No

Change in skin texture

Yes No

I authorize you to give me reasonable and proper medical care by today's standards.

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.

Patient Signature or guardian if minor

Date

Your information will be encrypted.