Microsoft word - new pt forms.pdf 9-2013.doc

THIS PATIENT INFORMATION FORM IS PART OF YOUR MEDICAL RECORD AND MUST BE COMPLETED IN ITS ENTIRETY
PATIENT INFORMATION FORM
(Middle)
BIRTHDATE
MARITAL STATUS: S M D W

HOME ADDRESS _____________________________________________________________________________________________________________________
___________
(Street)
HOME PHONE
____________
WORK PHONE
CELL PHONE
______________________
OCCUPATION
EMPLOYER NAME
__________
RESPONSIBLE PARTY INFORMATION: (IF OTHER THAN PATIENT)
(Middle)
RELATIONSHIP TO PATIENT_______________________________________________________________________________________________________________________________
SS# OF INSURED
______________________________ BIRTHDATE OF INSURED
HOME ADDRESS
____________
(Street)
(Zip Code)
HOME PHONE
I HAVE NO INSURANCE COVERAGE (PLEASE CHECK IF APPROPRIATE)
REFERRED BY PHYSICIAN FRIEND INTERNET
OTHER
__________ ________
PRIMARY CARE PHYSICIAN
____________________
EMERGENCY CONTACT
RELATIONSHIP
PHONE____________________________________________________________________________________________________________________________________________________
I do hereby agree to pay the full and entire amount of the consultation fee in addition to all bills for services rendered.
_____________________________________________________________________
(Sign Name)

As a member of a managed care group, I assume all responsibility for any services rendered that are not a part of my referral, whether or not covered or paid by
my insurance, and I will pay for those services at the time they are rendered.
___________________________________________________________
(Sign Name)

WORKER'S COMPENSATION AND OTHER PERSONAL INJURY TESTIMONY IN COURT
In order to provide the best possible service, care and availability to all of our patients, it is our policy not to testify in court, depositions, arbitrations, etc.
relating to Worker's Compensation and other personal injury action.
__________________________________________________________
(Sign Name)

Specialized Care
I understand that the Main Line Center for Laser Surgery is a tertiary referral practice. The physicians at our center will evaluate the specific problem for which
you have been referred or have sought treatment. General dermatologic care and evaluation is the responsibility of the referring or primary physician. If you
require a referral to a general dermatologist, please notify our office.
______________________________________________________________________
(Sign Name)
Reason for visit______________________________________________________________________________________________________________________
How long have you had this problem?_____________________________________________________________________________________________________
Name of General Dermatologist___________________________________________________________________________________________________________
Do you see a Skin Care specialist or Esthetician?______________________________________________________________________________________________
Have you ever been on Accutane? YES NO If yes please also inform the doctor verbally
If you were on Accutane when____________________________________________________________________________________________________________
Do you have or have a history of Cold Sores?
Do you have or have a history of Scarring or Keloids? NO
Have you recently had a hormonal work-up for excessive hair growth?
YES If yes when________________________________________________________
Do/have you ever had permanent makeup/tattoos? NO
YES If yes please also inform the doctor verbally

If yes where?
Lip liner Other_____________________________________________________________________
Have you ever had Gold Therapy?
YES If yes please also inform the doctor verbally

Do you faint when having blood drawn? NO

SOCIAL HISTORY: (CHECK ALL THAT APPLY)
Do you smoke?
YES - Frequency
Do you use recreational drugs? NO YES - Frequency____________________________
Do you drink alcohol? NO YES - Frequency
DRUG ALLERGIES: (LIST TYPE OF REACTION)
ANESTHETICS
ERYTHROMYCIN
PENICILLIN
TETRACYCLINE
OTHERS, please list
NON-DRUG ALLERGIES:
LATEX
OTHER (SPECIFY)
PRE-MEDICATION REQUIRED PRIOR TO SURGERY NO YES - List drug, dosage & duration
PRESENT/PAST MEDICAL HISTORY: (LIST CONDITIONS AND DATE)
_______________________________________________________________________________________________________________________________________________
ARE YOU CURRENTLY TAKING MEDICATION?
YES NO IF SO, PLEASE LIST:
SURGICAL HISTORY: (LIST TYPE, REASON FOR SURGERY, DATE, SURGEON)

_______________________________________________________________________________________________________________________________________________

REVIEW OF SYSTEMS AND PAST MEDICAL HISTORY OF PATIENT (CHECK ALL THAT APPLY; USE C. IF CURRENT, USE P IF PAST)
CONSTITUTIONAL SYMPTOMS:
RESPIRATORY:
NEUROLOGICAL:
GASTROINTESTINAL:
PSYCHIATRIC:
EARS, NOSE, MOUTH, THROAT:
Treatment of psychological disorder Other, specify ENDOCRINE:
GENITOURINARY:
HEMATOLOGIC/LYMPHATIC:
MUSCULOSKELETAL:
ALLERGIC/IMMUNOLOGIC:
CARDIOVASCULAR:
INTEGUMENTARY:
MALES ONLY:
FEMALES ONLY:
INFECTIOUS:
Currently taking oral contraceptives Date of last menses CANCER(S): (LIST TYPE, DATE, TREATMENT)
___________________________________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________________________________
DO YOU HAVE ANY FAMILY HISTORY OF SKIN CANCERS/MELANOMA? ____________________________________________________
PATIENT INFORMATION FORM
THE PRACTICE FINANCIAL POLICY WILL BE GIVEN TO PATIENTS AT THE TIME OF REGISTRATION.
ALL PATIENTS MUST SIGN THIS FORM.
OUR PRACTICE FINANCIAL POLICY
The physicians and staff at our office are dedicated to providing you with the best possible care and service, and regard your understanding of our financial policies as an essential element of your care and treatment. To assist you, we have the following financial policy. If you have any questions, please feel free to discuss them with our staff. Unless other arrangements have been made by either yourself or your health coverage carrier, full payment is due at the time of service. For your convenience, we accept Visa, MasterCard, American Express, Discover, Cash and Personal checks. YOUR INSURANCE
We have made prior arrangements with some insurers and other health plans. We will bill those plans with whom we have an agreement and will collect any required co-payment at the time of service. The copayment will be collected when you arrive for your appointment. In the event your health plan determines a service to be Anot covered@, you will be responsible for the complete charge. In that event, you will receive a statement at the time of service and payment is due at the time of service. If you have insurance coverage with a plan with which we do not have a prior agreement, we will prepare a statement for you to attach to your insurance claim form for processing of payment. In this case, the insurance carrier will send the payment directly to you. Therefore, charges for your care and treatment are due at the time service is rendered. Any balance due is your responsibility and is due upon receipt of a statement from our office. MINOR PATIENTS
For all services rendered to minor patients, the adult accompanying the patient is responsible for payment. MISSED APPOINTMENTS
In order to provide the best possible service and availability to all our patients, we ask that you please call us as early as possible if you know you will need to reschedule your appointment.
I have read and understand the financial policy of the practice and I agree to be bound by its items. I also understand
and agree that such terms may be amended from time-to-time by the practice.

_______________________________________________________________ (Signature of the Patient or Responsible Party) (Date) _______________________________________________________________ (Please Print the Name of the Patient)

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