Past Skin History (Please check the applicable boxes to the patient s history or choose the first box)
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- Rosaline Jackson
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1 Patient: First M.I. Last Date of Birth: Address: City: State: Zip Code: Responsible Billing Party: Social Security #: DOB: Home Work: Mobile: Best Contact number for confirmation calls is: (Required): I would like to receive statements and communications through . Y / N Primary Ins: Primary Card Holder: DOB: ID#: Group#: Secondary Ins: Primary Card Holder: DOB: ID#: Group #: Reason for your visit: Past Skin History (Please check the applicable boxes to the patient s history or choose the first box) No significant skin history Previous Treatments Treating Physician Notes Eczema Urticaria/Hives Psoriasis Basal Cell Carcinoma Actinic Keratosis Squamous Cell Carcinoma Malignant Melanoma Other Skin Cancer X-Ray Therapy Wounds that bleed easily or do not heal Ulcers Pneumovax/Influenza History (Required) Have you received a pneumonia vaccination in the past? Yes ( ) No ( ) Have you received the Influenza vaccination? Yes ( ) No ( ) List reason for not having vaccinations if any:
2 Past Medical History (Please check the applicable boxes to the patient s history or choose the first box) No Pertinent Past Medical History Arthritis Anemia Bleeding Disorders Asthma Hay Fever Tuberculosis, Emphysema or Lung Disorder Skin Cancer Breast Cancer Other Cancer High Cholesterol High Blood Pressure Heart Disease Chest Pain/Tightness Heart Murmur Congenital Heart Defect Rheumatic Fever History of Endocarditis/Heart Infection Diabetes Stroke Gastrointestinal Disease Hepatitis, Jaundice or other Liver Problems Compromised Immune System (HIV, AIDS, Lupus) Sexually Transmitted Disease Neurological Disorder Kidney Stones Thyroid Disorder Ulcers Details Past Surgical History (Please check the applicable boxes to the patient s history or choose the first box) Surgery Date Notes/Detail
3 Family History (Please choose the applicable boxes to the patient s family or choose the first box) No Contributing Family History Adopted Autoimmune Disorders Colon Cancer Diabetes Glaucoma High Blood Pressure High Cholesterol Liver Disease Lung Disease Malignant Melanoma Obesity Premature Coronary Heart Disease Skin Cancer Thyroid Disease Afflicted Family Member Notes Demographics (Required) Race: Ethnicity: (Hispanic/Non-Hispanic, etc.) Language: Allergies If none, please write None for Allergies Allergy Reaction Notes
4 Current Medications If none, please write None for Medications Medication Dosage Prescribed By Please list your preferred Pharmacy (include city): Social History (Required) Alcohol Do you drink alcohol? Yes ( ) No ( ) If yes: How many days per week do you drink? How many drinks per occasion? Smoking Status Smoking status: ( ) Current smoker ( ) Non-Smoker ( ) Chewing Tobacco If a previous or current smoker/chewing tobacco: When did you start? When did you quit? Height/Weight Height (Feet) Height (inches) Weight Details
5 Cosmetic Interest Are you interested in discussing treatment options for any of the following conditions? Facial Wrinkles Y N Sun Spots/Freckles Y N Age Spots Y N Dark circles under your eyes Y N Facial Redness/Veins Y N Leg Veins Y N Tattoo Removal Y N Verification All information provided above is accurate and complete to the best of my knowledge Patient Signature Parent or Guardian Signature (Minors) Date Notice of Privacy Practices Acknowledgement I am a patient of: Dr. Del Torto/Dr. Stranahan/Dr. Brandon/Erica Franks, PA-C. I hereby acknowledge receipt of Easton Dermatology's Notice of Privacy Practices. Name [please print]: Signature: Date: OR I am a parent or legal guardian of. (Print Patient Name) I hereby acknowledge receipt of Easton Dermatology's Notice of Privacy Practices with respect to the patient. Name [please print]: Relationship to Patient: Parent Legal Guardian Signature: Date:
6 Date: Patient Name: DOB: With your approval, we may disclose your personal health information to designated family, friends and others involved in your care or in payment of your care in order to facilitate that person s involvement in caring for you or paying for your care. By signing this authorization, I allow Easton Dermatology Associates, L.L.C., to discuss with the persons named below my personal health information which may include, but is not limited to, biopsy results, culture results, diagnosis, treatment plan, billing status and appointment status. This may be done in person or by telephone. By signing this authorization, I understand the following: This applies to services being rendered to me by the physicians and non-physician providers who practice under the name of Easton Dermatology Associates L.L.C. Once this information is released to the designated family member, friend or other person named below, the release information may no longer be protected by the federal privacy regulations. This authorization is voluntary I may withdraw this authorization at any time by notifying the Easton Dermatology Privacy Officer, Erica Franks, PA-C, in writing. If I do withdraw the authorization, it will not have any effect on actions taken by Easton Dermatology prior to receiving the written request. I authorize discussion of my personal health information with the following person(s): (PRINT CLEARLY) (1) Name: Phone: Relationship to Patient: (1) Name: Phone: Relationship to Patient FINANCIAL DISCLOSURE I understand that I am ultimately responsible for the balance on my account for any professional services rendered. Failure to make payment on any unpaid services can result in my account being sent to collections and/or legal action taken. If legal action is pursued, I will incur all court cost, attorney s fees and any other cost associated in the collection of this debt. I can also be discharged from the practice after a 30 day notice. I understand that I am responsible for paying a $ fee for dermatology appointments and $ fee for surgery or laser appointments if I do not call to cancel or reschedule. In the event of two consecutive NO SHOW appointments, I understand that I can be discharged from the practice. Patient/Guardian Signature Date Witness Signature Date
Patient Information. First Name Last Name M.I. Address: DOB: Sex: M F City: State: Zip: Social Security Number: / / Home Phone: ( )
Today's : Patient Information First Name Last Name M.I. Address: DOB: Sex: M F City: State: Zip: Social Security Number: / / Home Phone: ( ) Email: Work Phone: ( ) Primary Care Physican: Cell Phone: (
Patient Information. First Name Last Name M.I. Address: DOB: Sex: M F City: State: Zip: Social Security Number: / / Home Phone: ( )
Today's : Patient Information First Name Last Name M.I. Address: DOB: Sex: M F City: State: Zip: Social Security Number: / / Home Phone: ( ) Email: Work Phone: ( ) Primary Care Physican: Cell Phone: (
INSURANCE AND MANAGED CARE APPOINTMENT CANCELING POLICY
The physicians and staff of New England Dermatology & Laser Center value and appreciate your selection of our office for your skin care. We are committed to providing you with the best possible service.
PATIENT INFORMATION. Name: First Name MI Last Name. Date of Birth: / / Sex: Male / Female / Declined SSN:
PATIENT INFORMATION Name: First Name MI Last Name Date of Birth: / / Sex: Male / Female / Declined SSN: Race: Ethnicity: Hispanic/Latino Not Hispanic/Latino Declined Marital Status: Single Married Divorced/Separated
PLEASE PRINT PLEASE CHECK THE BOX AFTER THE PHONE NUMBER THAT YOU WANT AS YOUR PREFERRED NUMBER
NORTHERN VIRGINIA CENTER FOR ARTHRITIS PLEASE PRINT PATIENT REGISTRATION Patient s Name: DOB: Sex: Address: PLEASE CHECK THE BOX AFTER THE PHONE NUMBER THAT YOU WANT AS YOUR PREFERRED NUMBER Home#( ) [
6140 W Atlantic Avenue * Delray Beach, FL Tel: (561) * (888) 357-DERM * Fax: (561)
Cosmetic Patient Information Today s Date: Reason for visit: Patient Name: (Last) (First) (Middle) Permanent Address (Local): Street City/State/Zip Secondary (Out of State) Address: Street City/State/Zip
Patricia C. McCormack, M.D., F.A.A.D.
Patricia C. McCormack, M.D., F.A.A.D. Diplomate of the American Board of Dermatology Adult & Pediatric Dermatology www.patriciamccormackmd.com PATIENT INFORMATION Today s date: Last name: First name: of
Patient Registration. First Name: Last Name: Middle Initial: Address: City, State, Zip: First Name: Last Name: Middle Initial:
Patient Registration First Name: Last Name: Middle Initial: Preferred Name: DOB: Sex: Male Female Address: City, State, Zip: Home#: Cell#: Soc. Sec. #: Referred By: Previous Dentist: Responsible Party
PATIENT INFORMATION. RESPONSIBLE PARTY (If Different from Patient) POLICY HOLDER INFORMATION (If Different from Patient)
PATIENT INFORMATION Today s Date: Patient s Last Name: First: M.I. Mailing Address: City: State: Zip: Home Phone: ( ) Cell: ( ) Work: ( ) Date of Birth: / / Age: Sex: SSN: Driver s License #: Marital Status:
Patient Name: First MI Last Preferred Name. DOB: Sex: MALE FEMALE SSN: Address: City: State: Zip Code:
PATIENT DEMOGRAPHICS: Patient Name: First MI Last Preferred Name DOB: Sex: MALE FEMALE SSN: Address: City: State: Zip Code: Home Phone: _( ) Marital Status: Married Single Divorced Widowed Cell Phone:
Date: New Patient Form First Visit Date:
Date: New Patient Form First Visit Date: **PATIENT INFORMATION** **PRIMARY INSURANCE** Name: Insurance Company: Street: Claim Address: Facility/Complex City/state/Zip: Group #: Town/State/Zip: Policy/
Patient Last Name First Name Middle Name. Home Address City State Zip. Date of Birth Age Social Security # - - Cell Phone Home Phone Work Phone
Date Patient Last Name First Name Middle Name Gender (circle): Male Female Other: Marital Status (circle): Single Married Divorced Widowed Separated Home Address City State Zip Date of Birth Age Social
PATIENT MEDICAL HISTORY
Patients Name: PATIENT MEDICAL HISTORY Address: Date of Last Visit: Date of Med History City: State: Zip: Email: Home Phone: Work Phone: Birth Date: Social Security No: Marital Status: Primary Dental Guarantor:
MedDerm Associates, Inc.
*Last Name: PATIENT INFORMATION Please write CLEARLY and include any apt. # s, etc.., * Required information Today s Date: *First Name: *Primary phone: *Sex: M F Marital Status: S M W D DP *SS#: *Race
Pharmacy and Referrals Pharmacy Name, Street Address & Telephone #: Primary Care Physician s Name, Location & Telephone #:
Patient Registration Please Print Clearly Date: Last Name: First Name: Middle Initial: Sex: Date of Birth: / / Age: Social Security: - - Address: City: State: Zip Code - Circle Preferred Phone Number Home
F M S M W D. Age Birth Date Gender Marital Status Cell Phone
MIDWEST DERMATOLOGY CLINIC, PC Patient Legal Name Last First Middle Initial Today s Date Mailing Address Street City and State Zip Home Telephone F M S M W D. Age Birth Date Gender Marital Status Cell
Pharmacy and Referrals Pharmacy Name, Street Address & Telephone #: Primary Care Physician s Name, Location & Telephone #:
Patient Registration Please Print Clearly Date: Last Name: First Name: Middle Initial: Sex: Date of Birth: / / Age: Social Security: - - Address: City: State: Zip Code - Home Phone #: Work Phone #: Cell
Raymond G. Cavaliere, DPM 201 East 28 th St., Suite 1A New York, NY Tel # PLEASE FILL FORM OUT COMPLETELY, IF NEEDED USE N/A
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PATIENT INFORMATION. Last Name First Name MI. Address. City State Zip. Cell Phone _( ) Home Phone _( ) May we contact you by ?
PATIENT INFORMATION date: Last Name First Name MI Address City State Zip Cell Phone _( ) Home Phone _( ) Email May we contact you by email? Yes No Date of Birth Age Marital Status Patient s Occupation
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New Patient Information
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PATIENT REGISTRATION
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Laser Vein Center Thomas Wright MD RVT Page 1 of 4
Demographics Laser Vein Center Thomas Wright MD RVT Page 1 of 4 Patient Name: Address: City, St, Zip Primary Phone: Alternate: DOB: Social Security #: Marital Status: Married Single Other Emergency Contact:
Patient Profile. Full Name: Address: Work Phone: Date of Birth: Social Security #: (Circle One) Full Time / Part Time. Emergency Contact: Number:
Patient Profile Full Name: Address: City: State: Zip Code: Home Phone: Cell Phone: Work Phone: Date of Birth: Social Security #: Email Address: Employer: (Circle One) Full Time / Part Time Emergency Contact:
New Patient Intake Form
501 Islington Street, Suite 2B Portsmouth, NH 03801 P: 603-610-8882 F: 603-463-0943 New Patient Intake Form Personal Information Today s Date Name Age DOB: Phone: H ( ) W ( ) Cell ( ) Preferred Home Work
WHEN WAS YOUR LAST TEST OR IMMUNIZATION? PLEASE LIST PAST ILLNESSES, OPERATIONS, HOSPITALIZATIONS YOU HAVE HAD: TYPE: DATE TYPE: DATE
NAME: DATE: DOB: REFERRD BY: REASON FOR VISIT: ROUTINE PHYSICAL PROBLEM DESCRIBE PROBLEM: AGE: CHECK IF YOU HAD ANY OF THESE MEDICAL PROBLEMS IN THE PAST MAJOR ILLNESSES YES NO YES NO Anemia Hepatitis
Retinal Consultants of San Antonio PATIENT REGISTRATION
PATIENT REGISTRATION Today s Date Referred by Patient Full Name Home Address City State Zip Code Home Phone Cell Phone E-mail address Date of Birth Preferred Method of Contact: Home Phone / Cell Phone
Last: First: MI: Nickname:
New Patient Paperwork NAME: Last: First: MI: Nickname: ADDRESS: Street: City: State: Zip: DOB: Male Female SSN#: - - Home: ( ) Work: ( ) Mobile: ( ) Email: If applicable, Spouse s Name: Emergency Contact
EMERGENCY CONTACT INFORMATION: Name of contact: Address: Phone#: Relationship: May we release medical information to this person?
! Page 1 of 5 PATIENT INFORMATION: NAME (Nombre): DATE OF BIRTH (Fecha de Nacimiento): ADDRESS (Direccion): CITY (Ciudad): STATE(Estado): ZIP(Codigo Postal): TELEPHONE (HOME)(# Casa): CELL(# Celular):
Initial Clinical History and Physical Form
601 E FM 544, Suite 400, Murphy, TX, 75094 TEL: 972-442-4700 Initial Clinical History and Physical Form Patient Information Name: Age: of Birth: / / Sex: Male / Female Marital Status: Single Married Divorced
MEDICAL HISTORY QUESTIONNAIRE
MEDICAL HISTORY QUESTIONNAIRE Please print and complete this questionnaire prior to your first physical therapy appointment. The purpose of this questionnaire is to help us understand your health status.
Over. Signature of Patient/Parent/Guardian: Date: / / Date: / / Patient s Name: For ADULT Patients : Employer: Address: Occupation:
Date: / / Patient s Name: Address: Preferred Home: ( ) - Work: ( ) - Cell: ( ) - Text Message Reminders : Yes No Social Security #: Date of Birth: - - / / For ADULT Patients : Employer: Occupation: Spouse
COMPLAINTS (Briefly describe each complaint by order of severity): HAVE YOU EVER HAD FALLS, AUTO ACCIDENTS OR INJURIES?
CORAL REEF CHIROPRACTIC CENTER, PA NAME (Last, First, Middle Initial) HOME PHONE TODAY S DATE COMPLETE ADDRESS (Include City, State & Zip) CELL PHONE DATE OF BIRTH OCCUPATION EMPLOYER NAME EMAIL AGE SEX
PATIENT INFORMATION. Name Maiden Name Last First MI. Sex: M F Age Birthdate SSN - - Martial Status. Address
PATIENT INFORMATION Date Name Maiden Name Last First MI Sex: M F Age Birthdate SSN - - Martial Status Address City State Zip Home Phone Cell Phone Email Address Contact preference: Race Preferred Language
BOCA RATON PODIATRY, P.A. 950 GLADES ROAD #2A BOCA RATON, FL (561) fax Patient Information
Page 1 of 6 Patient Information Name: Date of Birth: Age: Address: Apt. # City State Zip S.S. #: - - Sex: M F Marital Status: M S D Sep W Partnered Phone: Home ( ) Work ( ) Cell ( ) Email: Employer: What
Cheralyn Perkins, DPM David Scalzo, DPM Kathleen Hope, DPM Nicole Branning, DPM TODAY S DATE: / / LEGAL NAME: LAST FIRST MIDDLE
PATIENT INFORMATION PATIENT INTAKE FORM BANGOR PODIATRY, LLC Cheralyn Perkins, DPM David Scalzo, DPM Kathleen Hope, DPM Nicole Branning, DPM TODAY S DATE: / / LEGAL NAME: LAST FIRST MIDDLE ADDRESS: STREET
The Premier Vein Center Evan Oblonsky MD 1051 W. Rand Road, Suite 104 Arlington Heights, IL Tel: Fax:
PATIENT INFORMATION (PLEASE PRINT) Patient Name: Nickname: Guardian: Date of Birth: Sex: Address: 2nd Address: Home Phone: Work Phone: Cell Phone: Best Number: License / ID# Contact Email: Emergency Contact:
Patient First Name: Last Name: Street Address: City: State: Zip Code. Mobile Phone: Home Phone: Work Phone:
Dr. Beth Kozak Welcome! New Patient Information Form Please provide us with the following information: Patient First Name: Last Name: Street Address: City: State: Zip Code Mobile Phone: Home Phone: Work