New Patient Intake Forms

PATIENT DEMOGRAPHICS:
Patient Name*
Date of Birth*

MonthDayYear
Date
Address*
Apt.
City*
State*
Zip*
Mobile phone*
Home phone
Consent for electronic communication*

YesNo
Email*
example@example.com
Biologic sex*

FemaleMale
Age
Race/Ethnicity
Marital status

SingleMarriedDivorcedWidowedPartnered
Emergency Contact Name*
Emergency Contact Relationship*
Emergency Contact Phone Number*
Preferred Pharmacy Name *
Preferred Pharmacy Phone Number*
Primary Care Physician
Primary Physician's Phone Number
Occupation*
Employer
Primary Insurance*
ID Number*
Group Number
Secondary Insurance
ID Number
Group Number
How did you hear about us?

My physician referred MeGoogleFriendOther
Name of Referring Physician or Friend
AUTHORIZATION TO RELEASE MEDICAL INFORMATION AND RECORDS:
Below, please list the name(s) and relationship of any person OTHER THAN YOURSELF that you authorize Vive Dermatology to release your medical information to.

I authorize the following third parties (i.e. spouse, parent, partner) to view or receive information regarding my care and record(s):
Name:
Do not put your name. If none, then leave blank.
Relationship
Patient Signature*

Clear
Date*

MonthDayYear
Date
MEDICAL HISTORY:
Reason for Visit #1*
Location*
What part of the body is affected?
Duration*
How long have you had this issue?
Treatment*
What are you currently taking/using for this issue?
Reason for Visit #2
Location
What part of the body is affected?
Duration
How long have you had this issue?
Treatment
What are you currently taking/using for this issue?
Reason for Visit #3
Location
What part of the body is affected?
Duration
How long have you had this issue?
Treatment
What are you currently taking/using for this issue?
Medications You Are Currently Taking*
If not taking any medications or using any topicals, write none.
Medication Allergies*
If you have no known allergies, write none.
What Kind of Allergic Reaction Do You Get?
Rash, Hives, Difficulty Breathing, etc.
Surgical History (include dates)*
If you haven't had any surgeries, then write none.
Personal History of Skin Cancer?*

YesNo
If Yes, What Type of Skin Cancer?

Basal CellSquamous CellMelanomaMerckel CellOther Skin Cancer
If Yes, Skin Cancer Location, Treatment and Dates
ie. Excision, Mohs Surgery, Radiation, Topical Treatment etc.
Family History of Skin Cancer?*

NoYesUnsure
If Yes, What Type of Skin Cancer?
REVIEW OF SYSTEMS:
Do you currently have or have you ever had any of the following? (check all that apply):*

AllergiesAnemiaArthritisAsthma/COPDArtificial JointsArtificial ValvesAutoimmune DiseaseCancerChemotherapyHigh CholesterolDepressionDiabetesHerpesHeart MurmurHepatitis or Liver IssuesHIV/AIDSHypertensionInflammatory Bowel DiseaseKeloids/Thick ScarsKidney IssuesRadiationThyroid Issues
Alcohol Consumption*

DailyOccasionallyNever
Smoking*

DailyOccasionallyNever
Aspirin or NSAID (ie. ibuprofen, naproxen) Use *

DailyOccasionallyNever
Are You Pregnant?

YesNo
Are You Nursing?

YesNo
Are You Using Hormonal Birth Control?

YesNo
Are You Taking Hormone Replacement Therapy?

YesNo
HIPAA PRIVACY PRACTICES NOTIFICATION:
I, the undersigned, have been issued the HIPAA Notice of Privacy Practices and this office’s “Patient Rights and Responsibilities". I fully understand that Vive Dermatology is required by law to maintain the privacy of my medical and health information. I acknowledge that the Practice will use and disclose any health information for the purposes of treating me, obtaining payment for services referred to me and conducting health care operations.
Patient Signature*

Clear
Date*

MonthDayYear
Date
REFERRALS:
I realize that my particular insurance plan might require a referral for me to be seen by any of the providers employed by Vive Dermatology. If at any time I fail to obtain a referral for a particular visit, I will be responsible for obtaining a valid referral from my primary care physician (PCP If a valid referral is not possible, I will be solely responsible for all charges. It is my responsibility to know whether or not my medical insurance carrier offers out-of-network benefits for non-participating physicians and to be aware of any deductibles, copays and co-insurances. I acknowledge and agree that I am fully responsible for any and all co-payment, co-insurance, deductible and/or other claim amount that my insurance company terms “patient responsibility".
Signature of Insured/Guardian*

Clear
Date*

MonthDayYear
Date
ASSIGNMENT AND RELEASE:
I certify that I (and/or my dependent(s have insurance coverage with the above-named insurance company(ies) and assign directly to Vive Dermatology (and its associated providers) all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. Vive Dermatology and associated providers may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services.
Signature of Insured/Guardian*

Clear
Date*

MonthDayYear
Date
OFFICE FINANCIAL POLICIES
CANCELLATION POLICY:
We understand that sometimes it is necessary to re-schedule an appointment. We ask at least 24 hours notice prior to cancelling and we will gladly reschedule. Monday appointments should be cancelled by noon the previous Friday. Please be sure to speak to our receptionist. Leaving a phone message, sending an email or text will not be considered a cancellation. If you arrive after your appointment was scheduled to begin, you will be seen but only for the amount of time remaining. If you are 15 minutes late, this will be considered a missed appointment. In the event that you are unable to give 24 hours’ notice, a cancellation fee of $50.00 for medical appointments, or $150.00 for cosmetic or surgical procedures will be billed to your account. We regret any inconvenience this may cause. Pre-paid packages are not refundable.
Patient Signature*

Clear
Date*

MonthDayYear
Date
CREDIT CARD ON FILE:
Vive Dermatology requires all patients to leave a valid credit card on file. By providing your credit card information below, you authorize payment for uncovered service and/or those that are determined to be your responsibility by your health plan. If you choose not to provide your credit card authorization, your account will be subject to a $25.00 statement fee per month for any outstanding balance over 30 days. Our practice has implemented stringent security measures to protect your credit card information and will make every attempt to contact you prior to charging your account.
Credit Card# (MC, VISA, DISCOVER):*
Exp:*
Security Code:*
Patient Signature*

Clear
Date*

MonthDayYear
Date
PHYSICIAN-PATIENT ARBITRATION AGREEMENT
Patient Signature*

Clear
Date*

MonthDayYear
Date
Insurance Card
Insurance Card Front
Insurance Card Back
Photo ID
Take Photo*
Should be Empty:

PATIENT DEMOGRAPHICS:

AUTHORIZATION TO RELEASE MEDICAL INFORMATION AND RECORDS:

MEDICAL HISTORY:

REVIEW OF SYSTEMS:

HIPAA PRIVACY PRACTICES NOTIFICATION:

REFERRALS:

ASSIGNMENT AND RELEASE:

OFFICE FINANCIAL POLICIES

CANCELLATION POLICY:

CREDIT CARD ON FILE:

PHYSICIAN-PATIENT ARBITRATION AGREEMENT

Insurance Card

Photo ID