Title: Dr/Mr/Mrs/Ms/Miss Last First M.I. Circle one. Primary Address: Street # Street name Apt# City State Zip

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Transcription:

Elissa S. Norton, MD 5162 Linton Blvd, Suite 203 P: (561) 877-3376 F: (877) 992-1153 info@brilliantdermatology.com Name: Title: Dr/Mr/Mrs/Ms/Miss Last First M.I. Circle one Primary Address: Street # Street name Apt# City State Zip Out-of-state Address: Street # Street name Apt# City State Zip Approximate start/end date at out-of-state address: DOB: Last 4 of SSN: Marital Status: Single/Married/Divorced/Widowed Race: Ethnicity: Hispanic Non-Hispanic Sex: M F Home phone Cell phone Email address: Primary care physician: Phone: Pharmacy name: Pharmacy phone: Emergency contact: Phone: Relationship: Employer name: Phone: Referred by: Physician (list name): Advertisment (list publicatiion): Friend (list name): Insurance listing Online search Policy Holder (person financially responsible if not self, not the main policy holder, or a minor): Name: DOB: Relationship to patient: SSN: Employer: The above information is true and current to the best of my knowledge

LIFETIME SIGNATURE AUTHORIZATIONS Consent for evaluation and treatment I authorize the physicians and assistants of Brilliant Dermatology & Aesthetics to administer medical care as deemed necessary on behalf of myself and/or dependents. Release of medical records: I authorize the release of medical information as necessary in order to process insurance claims, insurance applications and prescriptions, and to my primary care or referring physician. Assignment of benefits: I authorize payment of insurance benefits paid on my behalf be made directly to Brilliant Dermatology & Aesthetics. Financial responsibility: I understand I am personally responsible for all fees for services rendered in the course of treatment to me or my dependent including co-payments, deductibles, coinsurances, cosmetic services and any charges not covered. Payment is required for all services at the time they are rendered unless you are in a prepaid plan in which we participate. Specimens sent for pathology or laboratory services are billed separately. Outstanding balances over 90 days may be referred to a collection agency, with associated patient expense. We accept payment in the form of cash, check, or credit card. A $50 return check fee will be charged. Privacy Notice Acknowledgement I certify that I have been given the opportunity to read a copy of the Notice Of Privacy Practices, and may request a copy for my records. Your signature below signifies your understanding of the above authorizations and policies. I permit a copy of this authorization to be used in place of the original. Please present insurance cards and ID to Front Desk Brilliant Dermatology & Aesthetics P: (561) 877-3376 5162 Linton Blvd, Suite 203 F: (877) 992-1153

Release of Protected Health Information I allow the release of my health information to be shared with the following persons: My preferred phone is: (circle one) home or cell If my preferred phone is cell, I accept text messages for appointment reminders and other notifications: yes no It is okay to: Leave detailed messages regarding medical info such as Rx refills and follow-up after procedures - or Leave message with call back number only We do not leave biopsy results on answering machines Brilliant Dermatology & Aesthetics P: (561) 877-3376 5162 Linton Blvd, Suite 203 F: (877) 992-1153

Past Medical History: (please check all that apply) Medical History Anxiety Arthritis Asthma Atrial Fibrillation Bone Marrow Transplant BPH Breast Cancer Colon Cancer COPD Coronary Artery Disease Depression Diabetes End Stage Renal Disease GERD Hearing Loss Hepatitis Hypertension HIV/AIDS Hypercholesterolemia Hyperthyroidism Leukemia Lung Cancer Lymphoma Prostate Cancer Radiation Treatment Seizures Strokes Other Past Surgical History: ( Please check all that apply) Appendix Removed Bladder Removed Mastectomy (Right, Left, Bilateral) Lumpectomy (Right, Left, Bilateral) Breast Biopsy (Right, Left, Bilateral) Breast Reduction Breast Implants Colectomy: Colon Cancer Resection Colectomy: Diverticulitis, IBD Gallbladder Removed Coronary Artery bypass PTCA (angioplasty) Valve Replacement: mechanical or biological Heart Transplant Joint Replacement Knee(Right, Left, Bilateral) Joint Replacement Hip (Right, Left, Bilateral) Joint Replacement within last 2 years Kidney Biopsy Kidney Removed (Right, Left) Kidney Stone Removal Kidney transplant Ovaries Removed: Endometriosis, Cyst, Cancer Prostate Removed: Prostate Cancer Prostate Biopsy TURP- Prostatectomy Skin Biospy Basal Cell Carcinoma Surgery Squamous Cell Carcinoma Surgery Melanoma Surgery Spleen Removed Testicles Removed: (Right, Left, Bilateral) Hysterectomy: Fibroids,Uuterine cancer

Skin Disease History: (please check all that apply) Acne Hay fever/allergies Actinic Keratoses Melanoma Basal Cell Skin Cancer Poison Ivy Blistering Sunburns Precancerous Moles Dry Skin Psoriasis Eczema Squamous Cell Skin Cancer Flaky or Itchy Scalp Do you wear sunscreen? If yes, what SPF Do you tan in a tanning salon? Do you have a family history of Melanoma? If Yes, which relative(s)? Medications: (please list all current medications and supplements) NONE Allergies: (please list all allergies and the reaction you get) NONE Smoking Status: (please check all that apply) Alcohol Status: (please check all that apply) Current every day smoker Current some day smoker Former smoker Never smoked Alcohol consumption: NONE Less than 1 drink per day 1-2 drinks per day 3 or more drinks per day Cautions/Alerts: (please check all that apply) Pregnancy or planning a pregnancy Allergy to adhesive Allergy to topical antibiotic ointments Allergy to Lidocaine Rapid heartbeat with epinephrine Premedication prior to procedures Artificial heart valve Artificial joints within past 2 years Blood thinners Defibrillator Pacemaker History of MRSA History of vasovagal ( passing out after stress) Other:

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