PATIENT REGISTRATION (Please Print)

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14800 W. Mountain View Blvd., Suite 160 13090 N. 94 th Drive, Suite 101 Surprise, AZ 85374 Peoria, AZ 85381 (623) 584-3376 (623) 584-3376 Fax: (623) 584-3375 Fax: (623) 584-3375 PATIENT REGISTRATION (Please Print) SS#: - - PATIENT S NAME: (Last Name) (First Name) (Middle Initial) DATE OF BIRTH: / / SEX: ( M / F ) MARTIAL STATUS: ( S / M / W / D ) (Month) (Day) (Year) RACE/ETHNICITY: PRIMARY LANGUAGE: PERMANENT ADDRESS: APT #: CITY: STATE: ZIP: LOCAL ADDRESS: APT #: CITY: STATE: ZIP: HOME PHONE #: ( ) WORK PHONE #: ( ) CELL PHONE #: ( ) EMAIL ADDRESS: PRIMARY CARE PHYSICIAN: PCP PHONE #: ( ) HOW DID YOU HEAR ABOUT US?: PRIMARY INSURANCE Ins. Co. Name: Policy #: Group #: SECONDARY INSURANCE Ins. Co. Name: Policy #: Group #: EMERGENCY CONTACT NAME: DATE OF BIRTH: / / RELATIONSHIP TO YOU: CONTACT PHONE #: ( ) PARENT/GUARDIAN NAME(IF PATIENT IS MINOR): DATE OF BIRTH: / / WHO MAY RECEIVE INFORMATION REGARDING YOUR PROTECTED HEALTH INFORMATION? NAME: DATE OF BIRTH: / / RELATIONSHIP TO YOU: CONTACT PHONE #: ( ) May we leave messages regarding test results and appointments on your answering machine or other voice mail? (Check One) YES NO I have received a copy of the Privacy Rules from this provider and authorized the above list of persons who may receive my Protected Health Information. I may revoke this at any time by giving written notification to this provider. DATE: SIGNATURE: Circle One ( PATIENT / PARENT / GUARDIAN ) IF YOU HAVE TWO INSURANCE COMPANIES PLEASE PRESENT BOTH CARDS SO THAT WE MAY FILE WITH YOUR SECONDARY CARRIER FOR ANY BENEFITS DUE TO YOU.

Name: DOB: Date: New Patient History & Intake Form Past Medical History: (please circle all that apply) Anxiety Hepatitis Arthritis Hypertension Artificial Joints HIV/AIDS Asthma Hypercholesterolemia Atrial Fibrillation Hyperthyroidism BPH (Benign Prostatic Hyperplasia) Hypothyroidism Bone Marrow Transplantation Leukemia Colon Cancer Lung Cancer COPD (Emphysema) Pacemaker Coronary Artery Disease Radiation Treatment Depression Seizures End Stage Renal Disease Stroke GERD (Acid Reflux) Valve Replacement Hearing Loss None Other (Including any other type of cancer or any other problems you see a doctor for): Past Surgical History: (please circle all that apply) Appendix Removed Kidney Biopsy Bladder Removed Kidney Removed (left or right) Mastectomy (Left, Right, Bilateral) Kidney Stone Removal Lumpectomy (Left, Right, Bilateral) Kidney Transplant Breast Biopsy (Left, Right, Bilateral) Ovaries Removed: Endometriosis Breast Reduction Ovaries Removed: Cyst Breast Implants Ovaries Removed: Ovarian Cyst Colectomy: Colon Cancer Resection Prostate Removed: Prostate Cancer Colectomy: Diverticulitis Prostate Biopsy Colectomy: IBD TURP Gallbladder Removed Skin Biopsy Coronary Artery Bypass Basal Cell Carcinoma Surgery PTCA Squamous Cell Carcinoma Surgery Mechanical Valve Replacement Melanoma Surgery Biological Valve Replacement Spleen Removed Heart Transplant Testicles Removed (Left, Right, Bilateral) Joint Replacement, Knee (Left, Right, Bilateral) Hysterectomy (Fibroids) Joint Replacement, Hip (Left, Right, Bilateral) Hysterectomy (Uterine Cancer) Joint Replacement within the last 2 years None Other:

Name: DOB: Date: Skin Disease History: (please circle all that apply) Acne Hay Fever/Allergies Actinic Keratoses Melanoma Asthma Poison Ivy Basal Cell Carcinoma Precancerous Moles Blistering Sunburns Psoriasis Dry Skin Squamous Cell Carcinoma Flaking or Itchy Scalp None Other: Do you wear Sunscreen? Yes If yes, what SPF? No Do you tan in a tanning salon? Yes No Do you have a family history of Melanoma? Yes No If yes, which relative(s)? Medications: (Please enter all current medications, including the dose, if you know) Allergies: (please enter all medical allergies)

Name: DOB: Date: Social History: (please circle one) Cigarette Smoking Alcohol Use Per Day Never Smoked 0-1 Quit: Former Smoker 1-2 Smokes less than daily 3+ Smokes daily How often do you exercise? Once a day A few times a week A few times a month Never What is your caffeine use? Once a day A few times a week A few times a month Never Patient Data: Race: White Black/African American Asian American Indian/Pacific Islander Other Ethnicity: Hispanic/Latino Non-Hispanic/Latino Other: Preferred Language: English Spanish Other Pharmacy: Name: Cross Streets: Zipcode/City:

14800 W. Mountain View Blvd., Suite 160 13090 N. 94 th Drive, Suite 101 Surprise, AZ 85374 Peoria, AZ 85381 (623) 584-3376 (623) 584-3376 Fax: (623) 584-3375 Fax: (623) 584-3375 OFFICE POLICIES In effort to make your visit with us as easy as possible we ask that you make note of the following office policies. We thank you in advance for your cooperation. Please notify us of any changes to the following at the time of your visit: 1. Address 2. Insurance Information 3. Medical illness, injury, or surgery since your last visit 4. Medications added or discontinued since the last visit Please notify us of any appointment cancellation at least 48 hours in advance. We realize that circumstances may change and we are happy to accommodate your changing schedule. However, if you miss more than three (3) appointments without contacting us prior to the missed appointments we may assess you a missed appointment charge of fifty dollars ($50.00). Multiple no-shows may result in termination from our practice. Please allow 48 hours for prescription refill requests to be completed. Please note that we will not fill or refill any prescriptions for narcotic medications. All co-pays and deductibles are due at time of the visit. There will be a $30.00 returned check charge. There is a $25.00 fee for the completion of additional paperwork (cancer/disability policies, etc.) Assignment of Insurance Benefits: I hereby give authorization for payment of insurance benefit to be made directly to Arizona Dermatology Specialists, PLLC for services rendered. I understand that I am financially responsible for all charges whether or not they are covered by my insurance. In the event of default, I agree to pay all costs of collection, and reasonable attorney s fees. I hereby authorize my healthcare provider to release all information necessary to secure payment of benefits. Sincerely, The Staff Arizona Dermatology Specialists, PLLC Patient Acknowledged: Date:

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