New Patient Demographics Form
Please complete before your visit
PATIENT INFORMATION
Full Name
*
First Name
Last Name
Preferred Name
Date of Birth
*
-
Month
-
Day
Year
Date
SS # IF YOU ARE A VETERAN
Gender
*
Please Select
Male
Female
Prefer not to say
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Phone #
Please enter a valid phone number.
Type of Phone
Please Select
Cell
Home
Office
Other
Alternate Phone #
Please enter a valid phone number.
Email
*
example@example.com
Primary Care Doctor/Referring Provider
PCP Phone #
Please enter a valid phone number.
EMERGENCY CONTACT
Emergency Contact Full Name
Full Name
Last Name
EC Phone Number
Please enter a valid phone number.
Relationship to Patient
INSURANCE INFORMATION
Primary Insurance Type
Subscriber Name
Relationship to Patient
Subscriber Date of Birth
-
Month
-
Day
Year
Date
Subscriber Social Security #
Gender
Please Select
Male
Female
Prefer not to say
Secondary Insurance Type
Subscriber Name
Relationship to Patient
Subscriber Date of Birth
-
Month
-
Day
Year
Date
Subscriber Social Security #
Gender
Please Select
Male
Female
Prefer not to say
Tricare Patients: Sponsor Benefits #
GUARANTOR INFORMATION
(Responsible for billing)
Guarantor Name (if under 18)
Subscriber Name
Relationship to Patient
Phone Number
Please enter a valid phone number.
Address
How did you hear about us?
Yelp
Google
Family/Friend
Instagram/Facebook
Other
Patient Signature
*
Date
-
Month
-
Day
Year
Date
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Medical History
Past Medical History (Check all that apply)
Anxiety
Arthritis
Artificial Heart Valve
Artificial Joint
Asthma
Cancer
Diabetes
Depression
Hepatitis
High Blood Pressure
High Cholesterol
HIV/AIDs
Immunosuppression
Organ Transplant
Pacemaker/Defibrillator
Pregnant/Nursing
Radiation Treatment/History
Seizures
Thyroid: Hyper/Hypo
NONE
Other
Surgical History
Skin History (Check all that apply)
Actinic Keratosis
Basal Cell Skin Cancer
Blistering Sunburns
Cold Sores/Oral Herpes
Eczema
Fainting w/ Procedures
Hay Fever
Keloid Scarring
Melanoma
Precancerous Moles
Psoriasis
Reaction to local anesthetic
Squamous Cell Skin Cancer
NONE
Other
Do you wear sunscreen?
Yes (enter SPF in "Other field")
No
Other
Tanning salon use?
Yes
No
Previous
Family history of melanoma?
Yes
No
Medications (prescriptions, supplements, vitamins)
Allergies
Smoking Status
Never Smoker
Current Smoker
Former Smoker
Patients 65+
Have you had your pneumonia vaccine?
Yes
No
Have you established an advanced care plan?
Yes
No
Medical History, Page 1 Signature
*
Date
-
Month
-
Day
Year
Date
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Medical History
PAST MEDICAL HISTORY
Do you CURRENTLY have any of the following? Please check yes or no.
Yes
No
Problems with bleeding
Problems with scarring
Problems with healing
Rash
Immunosuppression
Unintentional weight loss
Night sweats
Fever of chills
Sore throat
Shortness of breath
Wheezing
Cough
Chest pain
Seizures
Headaches
Neck stiffness
Muscle weakness
Joint aches
Blurry vision
Bloddy urine/stool
Abdominal pain
On blood thinners
Allergy to adhesive
Allergy to lidocaine
Raid heart beat with epinephrine
Allergy to topical antibiotic ointments
Pharmacy
Preferred pharmacy (name and location)
Medical History, Page 2 Signature
*
Date
-
Month
-
Day
Year
Date
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Financial Office Policy and Consents
PATIENT RESPONSIBILITY FOR PAYMENT
Basic Policy:
Payment for service is due in full at the time the services are provided. For patients with insurance: Co payments are due at the time of service.
Missed Appointments
I understand that if my appointment is cancelled without a 24 hour notice or if it is deemed a no show I will be charged a $50.00 fee. For surgeries, we require 72 hours notice to cancel/reschedule and a $100.00 fee will be charged for all no shows/late cancellations. I also understand that repeated occurrences may result in release from this practice.
Returned Check Policy:
There will be a $40.00 fee for a check returned by the bank for any reason.
Account Payments
I understand that any balance due that is not paid within 60 days may be turned over to a collection agency and may increase for any recovery fees incurred by this process.
Authorization and Release:
I request that payment of authorized insurance benefits be made on my behalf to Hawaiian Islands Dermatology, LLC for any services rendered to me. I hereby agree to pay any and all charges that are not covered by insurance. I authorize the release of my medical information to my insurance company or Worker’s Compensation carrier that is necessary to determine benefits or the benefits payable for related services.
Privacy Practices Acknowledgment:
I have received and reviewed the private practices.
Patient Name
*
Full Name
Last Name
Privacy Practices Acknowledgement Signature
*
Date
-
Month
-
Day
Year
Date
MEDICAL RELEASE
Information may be released to the following family member/friend/etc:
Name
Full Name
Last Name
Relationship to Patient
Phone number
Please enter a valid phone number.
MEDICAL RELEASE
(optional)
Community Exchange:
I authorize Hawaiian Islands Dermatology, LLC to use any means of electronic transmission to any Healthcare Professional, Hospital or Healthcare Facility to exchange my Protected Health information.
Medication History:
I authorize Hawaiian Islands Dermatology, LLC to obtain my Medical History from our clearinghouse. The Medication History will include Medications prescribed by all Healthcare Providers.
Patient Referral:
I authorize Hawaiian Islands Dermatology, LLC to provide an electronic health record for each transition of care to another setting of care ( hospital, ambulatory primary care practice, ambulatory specialty care practice, long-term care. Home health, and rehabilitation facility) or provider of care or refer their patient to another provider.
Your signature below signifies your understanding and willingness to comply with the above policy and consent to the community exchange, immunization registry, medication history, and patient referral as described above.
Medical Release Signature (optional)
Date
-
Month
-
Day
Year
Date
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PRIVACY PRACTICES
This notice describes how your medical info may be used and disclosed.
Privacy use and disclosures:
We will use and disclose elements of your protected health information (PHI) in the following ways without your signed authorization. [LIST: Continuation of care by a specialist or another doctor; Release of information to your health plan for payment; Payment to physicians and hospitals who provide you with health care services; When release is required by law, including in judicial settings and to health oversight agencies and law enforcement; In emergency situations or to avert serious health/safety situations; To medical examiners, coroners or funeral directors to aid in identifying you or to help them in performing their duties to organ, tissue and other donation organizations; To contact you about appointment reminders, treatment alternatives and other health related benefits and services; All other uses and disclosure by us will require us to obtain from you a written authorization in addition to any other permission you will provide us] YOUR RIGHTS: You have the following rights concerning your PHI:[LIST: To inspect and request copies of your medical records or appeal any denial of your request for inspection or copying; To request that your health care provider append information to your medical record; To receive correspondence of confidential information by alternate means or location; To receive an accounting of the disclosures by us of your PHI; To get updates or reissue of this notice, at your request; To complain to us or the U.S. Dept. of Health & Human Services if you feel your privacy rights have been violated]How you can inspect, obtain copies of and/or amend your medical record:[LIST: If you wish to obtain copies of your medical records, send a written request to this office and you will be provided a full copy within 30 days; If you wish to attach information to improve the accuracy of completeness of your medical record, submit your request in writing to this office and this office and this information will be attached to your record. None of the digital records may be destroyed or erased.]We are required by law to maintain the privacy of your PHI. We must abide by the terms of this notice or any update of this notice.
Patient Name
First Name
Last Name
Privacy Practices Signature
*
Date
-
Month
-
Day
Year
Date
CONSENT FOR MEDICAL PHOTOGRAPHY
I consent for the medical photographs to be made of me or my child (or person whom I am legal guardian). I understand that the information may be used for my medical record only. By consenting to these medical photographs I understand that I will not receive payment from any party. Refusal to consent to photographs will in no way affect the medical care I will receive. If I have any questions or wish to withdraw my consent in the future I may contact Hawaiian Islands Dermatology, LLC.
Patient Name
First Name
Last Name
Consent for Medical Photography Signature
*
Date
-
Month
-
Day
Year
Date
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