Dermatology Consultation Form

Dermatology Consultation Form
Date*

MonthDayYear
Date
How did you hear about us?*
Are you being referred from a Primary Care of Specialty Care office?
Reason for the appointment*
Your Name*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
Address*

1234 Main St.

Apartment, Suite, etc. (optional)

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Biological Gender/Sex
Preferred Pharmacy:*
Preferred Pharmacy Address:*
Patient's Past Medical and Skin History (conditions that a Doctor has diagnosed you with in the past, i.e. diabetes, hypertension, skin cancer, etc). *
Patient's Past Surgical History (any surgeries that you've had in the past)*
Patient's Medication List (include current medications within the last 2 months, and Vitamins/supplements)*
Is the Patient a Smoker?

Never SmokerPast Smoker, Now QuitCurrent Smoker
Patient's Allergies to Medication please list, if none, list "none". *
Describe the patient's skin, hair or nail issue in detail. Please include, only 1 issue. Include how long it has been present, what things the patient has tried, and if any treatment worked or didn't work. Please be as detailed as possible.*
Please list the areas involved on the patient's body: (check off all that apply)*

ScalpNeckHandsBackGroinButtocksLegsFaceArmsChestAbdomenGenitalsThighsFeet
Please upload two clear pictures TAKEN IN GOOD LIGHTING AND FOCUS of your 1 primary issue.
First Picture of Condition*

Please submit a very clear picture of the condition
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Second Picture of Condition

Please submit a very clear picture of the condition
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Picture of Patient's ID card (license or any ID with a picture and address)*

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TELEHEALTH CONSENT FORM. Tele dermatology involves the use of electronic communications to enable health care providers at different locations to share individual patient medical information for the purpose of improving patient care. Providers may include primary care practitioners, specialists, and/or sub-specialists. The information may be used for diagnosis, therapy, follow-up and/or education, and may include any of the following:• Patient medical records• Medical images• Live two-way audio and video• Output data from medical devices and sound and video files. Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption. Expected Benefits:• Improved access to medical care by enabling a patient to remain in his/her dermatology’s office (or at a remote site) while the physician obtains test results and consults from healthcare practitioners at distant/other sites.• More efficient medical evaluation and management.• Obtaining expertise of a distant specialist. Possible Risks: AS with any medical procedure, there are potential risks associated with the use of tele dermatology. These risks include, but may not be limited to:• In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision making by the physician and consultant(s);• Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment;• In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information;• In rare cases, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors; 1. I understand the laws that protect privacy and the confidentiality of medical information also apply to tele dermatology, and that no information obtained in the use of tele dermatology which identifies me will be disclosed to researchers or other entities without my consent.2. I understand that I have the right to withhold or withdraw my consent to the use of tele dermatology in the course of my care at any time, without affecting my right to future care or treatment.3. I understand that I have the right to inspect all information obtained and recorded in the course of a tele dermatology interaction, and may receive copies of this information for a reasonable fee.4. I understand that a variety of alternative methods of medical care may be available to me, and that I may choose one or more of these at any time. My dermatologist and/or staff has explained the alternatives to my satisfaction.5. I understand that tele dermatology may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas, including out of state.6. I understand that it is my duty to inform my dermatologist of electronic interactions regarding my care that I may have with other healthcare providers.7. I understand that I may expect the anticipated benefits from the use of tele dermatology in my care, but that no results can be guaranteed or assured. I understand that National Telederm does not take insurance, and I am required to pay out of pocket for an evaluation. If your doctor is submitting this form on behalf of you as a curbside consultation, you understand that your physician is authorized to represent you, and you may be contacted for additional information.*

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My Products*

Dermatology VisitPlease be advised that the dermatology visits are limited to one dermatology condition per visit.

$109.99 Quantity

Total

$0.00

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

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Dermatology Consultation Form

Please upload two clear pictures TAKEN IN GOOD LIGHTING AND FOCUS of your 1 primary issue.