BLUEGRASS DERMATOLOGY Patient Registration Form

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Patient Registration Form PATIENT DEMOGRAPHIC INFORMATION Name: Chart Number: Social Security Number: Birth Date: Address: Apt. / Suite: City/State/Zip: E-mail Address: (REQUIRED FOR PATIENT PORTAL ACCESS) Home Phone: ( ) Cell Phone: ( ) Preferred Number: [ ]Home [ ]Cell Can we leave a detailed Message: [ ]Yes [ ] No Method for reminders? [ ] Phone call [ ] Text [ ] E-mail [ ] All Three Race: [ ] Caucasian [ ] African American [ ] Hispanic / Latino [ ] Asian [ ] American Indian [ ] Other Ethnicity: [ ] Hispanic [ ] Non-Hispanic Gender: [ ] Female [ ] Male Marital Status: [ ] Single [ ] Married [ ] Divorced [ ] Widowed Primary Language: Employer: Address: City/State/Zip: Work Phone: ( ) Emergency Contact Name: Relationship: Phone: ( ) RESPONSIBLE PARTY BILLING INFORMATION Relationship to Patient: [ ] Self [ ] Parent [ ] Guardian [ ] POA [ ] Other Name: Birth date: Address: City/State/Zip: Social Security Number: INSURANCE INFORMATION Primary: I.D. #: Group #: Effective Date: Subscriber Birth Date: Subscriber Name: Gender: Relationship to Patient: Secondary: I.D. #: Group #: Effective Date: Subscriber Birth Date: Subscriber Name: Gender: Relationship to Patient: I authorize the release of medical information to my primary care or referring physician, to consultants if needed and as necessary to process insurance claims, insurance applications and prescriptions. I also authorize payment of medical benefits to the physician. I understand that I am responsible for any charges deemed not medically necessary by my insurance company or otherwise not covered by my insurance company, including, but not limited to co-pays, deductibles and co-insurance payments. In order to establish optimal relations with our patients and avoid misunderstanding and confusion regarding our payment policies, our staff is trained to consistently inform you of the financial payment policies of this office. Payment is required for all services at the time they are rendered unless you are in a prepaid plan with which we participate. For those patients, applicable co-payments and deductibles will be collected. We accept payment in the form of CASH, CHECK, VISA, DISCOVER, AMERICAN EXPRESS, MASTERCARD, DEBIT CARDS, MONEY ORDERS, and CASHIERS CHECKS. We also participate with Care Credit Financing. All balances due that do not get paid within the first 30 days are subject to finances which will accrue interest monthly. PHARMACY AND PRIMARY CARE PROVIDER (Per Medicare and most insurances, you are required to list a primary care provider [PCP]) Pharmacy Name: Address: City/State/Zip: Phone: ( ) Physician: City/State/Zip: Phone: ( )

Patient Name: BLUEGRASS DERMATOLOGY Patient Medical History Form Birth Date: Chart Number: MEDICAL HISTORY (circle all that apply) [ ] I do not have any medical history problems and/or conditions Anxiety Asthma Bleeding Problems Blood Clots Cancer Depression Diabetes Heart Disease Hepatitis High Blood Pressure HIV / AIDS Inflammatory Bowel Disease Kidney Disease Liver Disease Migraines/Headaches Seizures SURGICAL HISTORY (circle all that apply) [ ] I do not have any past surgical history Skin Cancers Skin Biopsy Brain or Spine Surgery Breast or Gynecological Stroke Thyroid Disorders Tuberculosis Tumors Heart / Lung Surgery Joint Surgery Liver / Kidney Surgery Prostate or Testicular Stomach/Intestine/Colon Other Cancer Surgery SKIN MEDICAL HISTORY (circle all that apply) [ ] I do not have any skin medical history problems and/or conditions Basal Cell Carcinoma Melanoma Skin Cancer (unknown type) Squamous Cell Carcinoma Acne Actinic Keratoses Allergies Atypical or abnormal moles Blistering Sunburns Eczema Flaky or Itchy Scalp Poison Ivy Psoriasis Skin Infections Tanning Bed Use MEDICATION INFORMATION [ ] I am not currently taking any medications (List all medication you are currently taking and include all over-the-counter medications, herbals, vitamins, and minerals) It is important you fill in ALL of the fields for each medication Medication(s) Name (What is the name of the medication?) Strength Unit (Strength of medication) Route (How you take it? ie oral, injection, under tongue, etc) Dose (How many Dose Form (ie tablet, capsule,liquid, gel, etc) Frequency (How often is medication Indication (What medical condition does it treat?

Patient Medication/Allergy History Form Patient Name: Patient Birth Date: Chart Number: Medication(s) Name (What is the name of the medication?) Strength Unit (Strength of medication) Route (How you take it? ie oral, injection, under tongue, etc) Dose (How many Dose Form (ie tablet, capsule,liquid, gel, etc) Frequency (How often is medication Indication (What medical condition does it treat? ALLERGY INFORMATION Medication [ ] I do not have any allergies to any medications Allergic Reaction Do you have an allergy to Latex Products? o No o Yes Do you have an allergy to Adhesives? o No o Yes Do you have an allergy to Lidocaine? o No o Yes Do you have an allergy to Topical Antibiotic Ointments? o No o Yes SOCIAL HISTORY (Please answer ALL of the following questions) [ ] Never smoker and/or tobacco user [ ] Former smoker and/or tobacco user [ ] Current smoker and/or tobacco user [ ] I do not drink alcohol [ ] I drink alcohol [ ] I have had flu vaccine current / past flu season [ ] I have not had flu vaccine [ ] I do not take flu vaccine [ ] I am allergic to the flu vaccine [ ] I have had pneumonia vaccine [ ] I have not had pneumonia vaccine [ ] I do not take pneumonia vaccine [ ] I am allergic to the pneumonia vaccine Surrogate Decision Maker (i.e. Living Will, POA, or family member / friend who can help you in medical emergencies) [ ] I have a surrogate decision maker [ ] I do not have a surrogate decision maker [ ] I have a living will [ ] I have a POA If you have a surrogate decision maker, who is it? Phone: ( ) FAMILY HISTORY (circle all that apply) [ ] I do not have a family history of any medical conditions Please do not include yourself and/or spouse and only list family member(s) who had the medical condition Melanoma (family member ) Cancer (family member ) Other Skin Cancers [unknown type] Diabetes (family member ) (family member ) Eczema or Psoriasis (family member ) Other Pertinent Family History

Patient Review of Systems Questionnaire Form Are you currently experiencing any of the following? (Please mark Yes or No for the following): SYMPTOMS SYMPTOMS Abdominal Pain o No o Yes Rash o No o Yes Blurry Vision o No o Yes Problems with Bleeding o No o Yes Chapped Lips o No o Yes Problems with Scarring/Healing o No o Yes Depression o No o Yes Changing Mole o No o Yes Dry Skin o No o Yes Thyroid Problems o No o Yes Headaches o No o Yes Sore Throat o No o Yes Joint Pain o No o Yes Muscle Weakness o No o Yes Swollen Lymph Nodes o No o Yes Night Sweats o No o Yes Fever and Chills o No o Yes Seizures o No o Yes Cough o No o Yes Heartburn o No o Yes Nausea or Vomiting o No o Yes Wheezing o No o Yes Unintentional Weight Loss o No o Yes Please mark Yes or No for the following: Do you take a blood thinning medication? Common blood thinning medications are: Aspirin, Brilinta (Tricagrelor), Coumadin (Warfarin), Plavix, Pradaxa, Xarelto, Imbruvica (Ibrutinib) o No o Yes Do you have an artificial heart valve? o No o Yes Do you require antibiotics prior to a surgical procedure? o No o Yes Do you have a defibrillator and/or pacemaker? o No o Yes Have you had an artificial joint replacement within the past two (2) years? If yes, when and what body locations? o No o Yes Have you been diagnosed as having human immunodeficiency virus (HIV)? o No o Yes Have you been diagnosed as having Hepatitis B or C? o No o Yes FEMALE PATIENTS PLEASE ANSWER THE FOLLOWING QUESTIONS: Are you trying to become pregnant? o N/A o No o Yes o Maybe Are you currently pregnant? o N/A o No o Yes o Maybe Are you currently nursing? o N/A o No o Yes If you are of child-bearing potential, are you using o N/A o No o Yes contraception? If yes, what contraception are you currently using?

Driving Directions to the Office Hours of Operation: Monday Thursday: 8 am 6 pm Friday: 8 am 5 pm Closed: Weekends and Major Holidays Coming From Interstate 75 South: 1. At exit 104, take ramp right for KY-418 toward Lexington / Athens. 2. Turn left onto SR-418 / Athens Boonesboro Rd 3. Road name changes to US-25 North / US-421 North / Richmond Rd. 4. Turn right onto Yorkshire Blvd, our parking lot is the first drive to your left. Coming From Interstate 75 North: 1. Take the Man O War Blvd exit #108 KY-1425W. 2. Stay straight on Man O War Blvd and turn left onto Polumbo Drive. 3. Stay straight on Polumbo Dr, there will be a sharp turn to the right and the road name changes to Yorkshire Blvd. 4. Stay on Yorkshire Blvd to the end. Our parking lot is the last drive on your right. Coming from New Circle Road: 1. Take the US-25S./US-421S. exit #15 towards Richmond / Interstate 75. 2. Stay on Richmond Rd heading towards Interstate 75. 3. After crossing Man O War Blvd, turn left at the 2 nd traffic light, onto Yorkshire Blvd. 4. Our parking lot is the first drive to your left. Coming from the Bert T. Combs Mountain Parkway: 1. Take the Mountain parkway to Interstate 64 W. 2. Merge onto I-75 S. via exit 81 on the left towards Richmond / Knoxville. 3. Take the Man O War Blvd exit#108 KY-1425W. 4. Stay straight on Man O War Blvd and turn left onto Polumbo Drive. 5. Stay straight on Polumbo Dr, there will be a sharp turn to the right and the road name changes to Yorkshire Blvd. 6. Stay on Yorkshire Blvd to the end. Our parking lot is the last drive on your right.

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