Patient Registration Form: PATIENT INFORMATION Name: Date of Birth: Sex: Street Address: City/State Zip Code:

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For office use only: EMA Centricity Insurance Patient Registration Form: PATIENT INFORMATION Name: Date of Birth: Sex: Street Address: City/State Zip Code: Race: Ethnic Group: Preferred Language Marital Status: Employer/Place of Employment: Single Married Divorced Widowed Employer Phone number: Social Security Number: Spouse Name (if applicable) Caretaker Name (if applicable) Cell Phone: Home Phone: Work Phone: Circle your preferred contact method Medical Information Release (Privacy Policies are located at the reception desk) May we leave a message for you to return our call? May we leave a message for you to return our call? May we leave a message for you to return our call? Cell Home Work Email ***IF you would like text messages sent to your cell phone for appointment reminders please text: DSWO to 622622 If you are not available may we leave a message with another person? If yes, please state below: Name/Relationship Phone Email Address: Emergency Contact: Name/Relationship Phone Pharmacy: *our office does electronic prescriptions please list as much information as possible* Name: _ Location: Phone: Have you ever been seen by one of our physicians? (if yes, physician name) Primary Care Provider: Full Name: Location: Phone: Fax: Did your Primary Care Provider refer you? Were you referred by another physician? Yes IF yes: Name of referring Provider How did you hear about our office (check all that apply)? Internet Radio Yellow Pages TV Newspaper Friend Relative Doctor Other Signature of Responsible Party/Date

Dermatologists of Southwest Ohio and Dermatologists of Greater Columbus Financial Policy Thank you for choosing Dermatologists of Greater Columbus. The following is our financial policy. Please review the policy, initial where indicated, sign and date at the bottom. Paperwork: We request you routinely update your paperwork to ensure we have all the correct information on hand for billing purposes and to ensure excellent clinical care. This paperwork allows us to bill insurances in a timely manner and from preventing balances being unnecessarily transferred to you, the patient. We understand the frustration of completing paperwork and are constantly evaluating different methods to reduce the burden on you. Missed appointments/cancellations: We request 24 hour advanced notification of cancellations and reschedules. We try to notify all patient of upcoming appointments using our computerized calling system. Unfortunately, we do experience errors with the system from time to time. We do not charge for missed appointments or cancellations. Frequently missed appointments and cancellations can results in dismissal from our practice. Insurance: Our practice is contracted with most commercial insurances and Medicare. We do not accept Medicaid. As a contracted provider, we agree to accept adjusted fees from your insurance company and bill in accordance with CPT and ICD 10 guidelines. We collect co-pays at the time of visit. Deductibles and other outstanding balances will be billed to you, after your claim has been processed by your insurance company. We are unable to determine prior to your visit what charges will be applied to your deductible. The patient is responsible for providing the most up to date insurance information prior to, or at the time of service. Patient is responsible for payment of services rendered in the event they incorrect insurance information was provided at the time of service. Available forms of payment include: cash, check, MasterCard, and Visa. We Do Not accept Discover or American Express. Cosmetic Procedures: Payment is expected in full at the time of your procedure. Lab Fee: Dermatologists of Greater Columbus and Dermatologists of Southwest Ohio use an outside laboratory for pathology services. The lab will bill you directly for these services. Patient is Responsible for Total Charge: Patients will be billed in full for any unpaid copayments or deductibles. Patient balances will be set by the adjusted rates as determined by our contract with your insurance company. In accordance with our contracts and Medicare guidelines we cannot make adjustments to these fees or the codes charges. If your insurance requires a referral and the necessary referral was not obtained prior to services rendered the patient (or party responsible for billing as listed below) is responsible for total payment of services rendered. My Signature below indicates that I have read and agree to the above written financial policy of Dermatologists of Greater Columbus. Signature of Responsible Party/Date

Insurance Information: Does your insurance require a referral? If yes please list all physician information on page 1 Primary Insurance Insurance Name/Phone: Insurance Effective Date Subscriber s Policy Number Group No. Specialty Co-Pay $ Subscriber s Name and Address (if different from patient) Subscriber s Date of Birth Subscriber s Social Security Number Secondary Insurance Insurance (Secondary) Insurance Effective Date Insurance Phone: Subscriber s Policy Number Group No. Specialty Co-Pay $ Subscriber s Name and Address Subscriber s Date of Birth Subscriber s SSN Person Responsible for Payment if Other than Patient Billing Name Social Security Number Date of Birth Phone Number Relationship to Patient Employer Address Recent Insurance policy changes and the popularity of high deductible plans have increased the number of bills and balances to patients. If you have not met your deductible for your plan year, please expect a bill from our office. Per our insurance contracts we are unable to make adjustments to any outstanding balance. Signature of Responsible Party/Date

PATIENT INFORMATION Name: Date of Birth: Account #: Latex allergy? Any drug allergies? If yes, list any drugs you are allergic to: Yes Yes MEDICAL SYMPTOMS Please check all the apply Anxiety Arthritis Asthma Atrial fibrillation Bone Marrow Transplant BPH (benign prostatic hyperplasia) Breast Cancer Colon Cancer COPD Coronary artery disease Depression Diabetes End Stage Renal Disease GERD Hearing Loss Hepatitis Hypertension HIV/AIDS Hypercholesterolemia Hyperthyroidism Hypothyroidism Leukemia Lung cancer Lymphoma Prostate cancer Radiation Treatment Seizures Stroke Other ne Appendix: (appendectomy) Bladder: (cystectomy) Breast: Breast Biopsy Breast: Lumpectomy (both breasts) Breast: Lumpectomy (left breast) Breast: Lumpectomy (right breast) Breast: Mastectomy (both breasts) Breast: Mastectomy (left breasts) Breast: Mastectomy (right breasts) Colon (colectomy): Colon Cancer Resection Colon (Colectomy): Diverticulitis Colon (Colectomy): Inflammatory Bowel Colon: Colostomy Gallbladder: (cholecystectomy) Heart: Biological Valve Replacement Heart: Coronary Artery Bypass Heart: Heart Transplant Heart: Mechanical Valve Replacement Heart: PTCA (angioplasty) Joint Replacement: Hip (both) Joint Replacement: Hip (left) Joint Replacement: Hip (right) Joint Replacement: Knee (both) Have you had any surgeries on the following Organs Joint Replacement: Knee (left) Joint Replacement: Knee (right) Kidney: Kidney Biopsy Kidney: Kidney Stone Removal Kidney: Kidney Transplant Liver: Hepatectomy Liver: Liver Transplant Liver: Shunt Ovaries: (oophorectomy): Endometrosis Ovaries: (oophorectomy): Ovarian Cancer Ovaries: Tubal Ligation Pancreas: Pancreatectomy Prostate: (prostatectomy): Prostate Biopsy Prostate: (prostatectomy): Prostate Cancer Prostate: (prostatectomy): TURP (transurethral resection) Rectum: APR (abdominal perineal resection) Rectum: Low anterior resection Skin: Basal Cell Carcinoma Skin: Melanoma Skin: Skin Biopsy Skin: Squamous Cell Carcinoma Spleen: (splenectomy) Testicles: (orchiectomy) Please check all the apply Uterus: (hysterectomy): Fibroids Uterus: (hysterectomy): Uterine Cancer Uterus: (hysterectomy): Cervical Cancer Other ne Acne Actinic Keratosis (pre skin cancer) Basal Cell Skin Cancer Blistering Sunburns Dry Skin Eczema Have you had any of the following conditions: Flaking or Itchy Scalp Hay Fever/Allergies Melanoma Poison Ivy Precancerous Moles Psoriasis Squamous Cell Skin Cancer Other _ ne Do you wear sunscreen? Yes If Yes, what SPF? Are you currently pregnant? Previous history of pregnancies/births (list years) Do you tan in a tanning salon? Do you have a family history of melanoma? If yes, which relative? Signature of Responsible Party/Date

Are you currently taking any of the following? Coumadin/Wafarin Pradaxa Effient Plavix Aspirin Medications (list all prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary supplements as well as name/dosage/freq/route) Medication Name Dosage Frequency Route Tobacco Products Use? Current every day smoker Former every day smoker Never Date Started/Quit Have you ever tested positive for TB? Alcohol: None Less than 1 drink/day 1-2 drinks daily 3 or more drinks daily SOCIAL HISTORY How many times in the past year have you had 5 or more drinks in a day for men, or 4 or more drinks in a day for women (or any adult over the age of 65)? Please provide the approximate number in the space provided Have you received your flu vaccination? What year? Have you received your pneumonia vaccination? REVIEW OF SYSTEMS History or current problem with any of the following? (Please check all that apply) Problems with bleeding Night Sweats Blood thinners Problems with healing Rash/Hives Problems with scarring (hypertrophic or keloid) Seizures Shortness of Breath Abdominal Pain Sleeplessness Anxiety Sore Throat Bloody Stool Thyroid Problems Bloody Urine Unintentional Weight loss Blurry Vision Vaginal Candidiasis Chest Pain Wheezing Cough Red Eye Depression Tearing Dizziness Eye Pain Fever or Chills Uncontrolled Blood Pressure Grey Discoloration of Skin Elevated Blood Sugar Hay Fever Allergy to adhesive Headaches Allergy to Lidocaine Defibrillator MRSA Pacemaker Currently Pregnant or planning a pregnancy Premedication prior to procedures Rapid heartbeat with epinephrine Ebola Risk: Fever >+100.4 West Africa: Travel or contact Ebola Risk: contact w/ebola patient without Proper protective equipment within the last 21 days Ebola Risk: Headaches, weakness, muscle pain Immunosuppression --------------------------------------------------------- Vomiting, diarrhea, abdominal pain, and/or Joint Aches Allergy to topical antiobiotic ointments Hemorrhage (if yes, indicate year ) Menstrual Changes Artificial heart valves Prostate Medications Muscle Weakness Artificial joints in the last 2 yrs Transplant Neck Stiffness Blood thinners Signature of Responsible Party/Date

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