MAIN STREET DERMATOLOGY MEDICAL INTAKE & CONSENT FORM

MAIN STREET DERMATOLOGY MEDICAL INTAKE & CONSENT FORM
Please check if assistance was needed to complete this form
Patient Name
If unable to make medical decisions (see responsible party)
DOB
Patient phone #
Patient email address
Community/Facility Name
Please select the option that best describes your community

Independent LivingAssisted LivingMemory CareNursing Home/Skilled NursingHospice
Patient address (Facesheet or copy of ID)

Facesheet or copy of ID if available
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Street Address
Apt/Unit/Room
City
State
Zip
Responsible Party Name/POC and relation to patient
Responsible party phone #
Responsible party email address
Responsible party ID (If not on facesheet)

File upload if available
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Street Address
Apt/Unit/Room
City
State
Zip
Preferred payment option

Credit card on fileMail invoice to patientMail invoice to responsible party

My Services

USDInsurance copay for specialist visit or patient self-pay/cash pay

Payment Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Chief skin concern(s)
Medication allergies

YesNo
Medication allergies upload or list below

File upload
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Please list medication allergies
Primary care physician
List of surgeries/hospitalization & dates
List of current medications
Medication list upload

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Personal history (Please check all that apply)

Pre-skin cancerBasal cell carcinomaSquamos cell carcinomaMalignant melanomaEczemaPsoriasisHeart diseasePacemakerArtificial heart valveDiabetesCancerHigh blood pressureThyroid problemsBreathing problemsBleeding disorderStomach/Intestinal problemsKidney problemsDementiaStroke
Social history
Smoker

YesNo
How often

EverydaySome daysFormer smoker
Drink achohol

YesNo
How often

DailyOccasionally
Family history (Mother, Father or siblings)
Financial disclosure: We accept Medicare and all major health insurance plans, subject to plan co-pays, deductibles and exclusions. We do not accept Medicaid. We offer self-pay / cash pay options. If the insurance company does not cover the services for any reason, it is your responsibility to pay us promptly for any services rendered. If a payment to us becomes 30 days past due, it is considered delinquent. We do not issue refund checks for any balance less than $30. Instead, we will apply the credit towards your next balance due. Sometimes we use an outside laboratory to perform certain tests and you are responsible for all costs incurred by the lab which are not covered by your insurance. In the event of non-payment, I will bear the cost of collection proceedings should this be required.

HIPAA Consent: With my consent, Main Street Dermatology may use and disclose my protected health information (PHI) about me to carry out treatment, payment and health care coordination. Please refer to our Notice of Privacy Practices for a more complete description of such uses and disclosures-available upon request.

Consent to Treat: voluntarily give my consent for treatment/ procedures that are performed by Main Street Dermatology and deemed necessary for my condition.

I voluntarily give my consent for treatment / procedures that are performed by Main Street Dermatology and deemed necessary for my condition
SIGNATURE OF PATIENT OR PATIENT ADVOCATE/HEALTHCARE POWER OF ATTORNEY

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DATE

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Date
If you have any questions or concerns, please call us at (248) 238-8059 or email us at info@mainstreetdermatology.com
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