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New Patient Intake
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Name Prefix (Choose One)
Mr.
Mrs.
Ms.
Miss
Dr.
Rev.
Fr.
Sr.
Name
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Primary Phone
Secondary Phone
Email Address
Birth Sex
Male
Female
Age
Date of Birth
MM slash DD slash YYYY
Race/Ethnicity (choose one)
Hispanic/Latino
Not Hispanic/Latino
Marital Status
Single
Married
Divorced
Widowed
Employment Status
Employed Full-Time
Employed Part-Time
Self-employed
Homemaker
Retired
Student Full-Time
Student Part-Time
Employer
*
Occupation
*
Responsible Party Name (if patient is minor)
Relationship
Emergency Contact
Emergeny Contact Phone
Relationship
Referring/Primaring Physician(s)
Phone Number
Pharmacy Name w/cross streets
Pharmacy Phone
How did you hear about Derm Haven?
I agree to receive periodic specials and promotions.
Yes
No
Primary Insurance Name
ID #
Group #
Insured Name (if other than self)
Insured's Date of Birth
MM slash DD slash YYYY
Insured's SS#
Insured's Phone
Insured's Address (if other than self)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Insured's Employer
Relationship of patient to insured
Self
Spouse
Son
Daughter
Stepchild
Other
Section Break
Secondary Insurance Name
ID #
Group #
Insured Name (if other than self)
Insured's Date of Birth
MM slash DD slash YYYY
Insured's SS#
Insured's Phone
Insured's Address (if other than self)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Insured's Employer
Relationship of patient to insured
Self
Spouse
Son
Daughter
Stepchild
Other
I wish to be contacted in the following manner (check all that apply):
Home Phone
OK to leave message with detailed information
Leave message with call back number only
Work Phone
OK to leave message with detailed information
Leave message with call back number only
Cell Phone
OK to leave message with detailed information
Leave message with call back number only
Written Letters
Mail to my home address
Mail to my work/office address
OK to fax
OK to email
Please give those listed below access to my protected health information (PHI).
Name
Relationship
Contact Number
Name
Relationship
Contact Number
Or:
I do not authorize Derm Haven to release protected health information (PHI) to anyone at this time.
NOTE: Uses and disclosures may be permitted without consent in emergency.
Consent
*
I have read, understand, and agree to the Financial Policy guidelines. I acknowledge that I have seen the HIPAA policy posted and I agree with the terms and conditions as stated.
Patient Name
Date
MM slash DD slash YYYY
Patient/Guarantor Signature
Medical Questionnaire
Have you ever had reactions to local anesthetics?
Yes
No
If yes, explain.
*
Do you have drug allergies?
Yes
No
If yes, please list:
Medications/non-Rx medications that you currently take w/dose, including prescriptions from this office (one per line)
Do you have a PERSONAL HISTORY of, or are currently under treatment for, the following conditions?
Heart Problems
Hepatitis
Organ Transplant
High Blood Pressure
Diabetes
PUVA/UVB
Kidney Problems
Arthritis
Cancer
Stroke
Blood Clots
Accutane (past 3 months)
Epilepsy
Bleeding Problems
Currently Pregnant/Nursing
Keloid scars
Rheumatic Fever
HIV
Artificial Joint/Valve
Psychiatric Conditions
Skin Cancer
Dry Skin/Eczema
Melanoma
Precancerous lesions or moles
Do you have a family history of malignant melanoma?
Yes
No
If yes, who?
Do you use tobacco?
Yes
No
Types and amounts used
Have you previously had surgery?
Yes
No
If yes, explain type & give dates (mo/yr) of each
Allergies/Sensitivities (check all that apply)
Tape/adhesives
Polysporin/Neosporin
Latex
Lidocaine or Epi
Bee Sting
Other
Have you ever had a mammogram?
Yes
No
If yes, date of last screening.
Have you ever had a colorectal screening?
Yes
No
If yes, date of last screening.
Do you have any history of MRSA infections?
Yes
No
Have you received a pneumonia vaccination in the past year?
Yes
No
Have you received an influenza vaccination in the past year?
Yes
No
Do you use sunscreen?
Yes
No
If yes, what SPF?
Do you now tan indoor or outdoor?
Yes
No
Name
This field is for validation purposes and should be left unchanged.
