NEW PATIENT INTAKE FORM

New Patient Form
How did you hear about us?*
Patient's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Social Security Number
Gender*

MaleFemaleOther
Marital Status*

SingleMarriedDivorcedWidowOther
Race*

WhiteBlack or African-AmericanAmerican Indian or Alaska-NativeNative-Hawaiian or other Pacific IslanderAsianOther
Ethnicity*

Hispanic or LatinoNon-Hispanic or Latino
Home Phone Number*
Please enter a valid phone number.
Cell Phone Number*
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Preferred Phone*

HomeCellWork
Is it OK to leave a detailed message?*

YesNo
Email*
example@example.com
Patient Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Pharmacy Name*
Pharmacy Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Pharmacy Phone*
IV Drug Use?*

YesNo
IV Drug Use within past 12 months?*

YesNo
Alcohol Use?*

YesNo
Do you give us consent to speak to your emergency contact?*

YesNo
If yes, what is their name and relationship to you and their telephone number?
Past Medical History (Select all that apply)*
SURGICAL HISTORY (list all surgeries)*
Skin Disease History (Select all that apply)*

AcneActinic KeratosisSkin Cancer - Basal Cell CarcinomaSkin Cancer - Squamous Cell CarcinomaMelanomaBlistering SunburnPrecancerous MolesPsoriasisEczemaOtherNone
Do you wear sunscreen?*

YesNo
Do you tan in a tanning salon?*

YesNo
Family History of Melanoma?*

YesNo
If yes, which relative?

MotherFatherSisterBrotherDaughterSonUncleAuntNephewNieceGrandmotherGrandfather
MEDICATIONS (Please list or give to front desk)*
Any allergies to medications?*

YesNo
If Yes, what medications?
FEMALES ONLY: Date of last menstrual period?
FEMALES ONLY: Menopausal?

YesNo
Smoking History:*

Current every day smokerFormer smokerNon-smoker
Please select any of the following that are applicable:*

PacemakerDefbrillatorPremedication prior to procedureAllergy to adhesiveBlood ThinnersPregnancy or planning a pregnancyAllergy to lidocaineHave been given NovocainHave been given EpinephrineProblems with BleedingArtificial joints within past two yearsArtificial heart valveNone
Are you your own Power of Attorney?*

YesNo
REASON FOR YOUR VISIT TODAY?*
Do you give consent to electronically update medication list from your pharmacy?

YesNo
Do you give consent to update your patient portal?

YesNo
Primary Care Physician Name:
Primary Care Physician Telephone Number:
No Show / Cancel Policy: All no shows and patients who cancel their appointments without 24-hour notice will be charged a fee of $50 - Please initial that you understand and agree:*
Our office will call you to confirm one business day before your appointment time. Please be aware that your APPOINTMENT will be cancelled if it is NOT CONFIRMED by you. Please initial that you understand and agree:*
Sign*

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Today's Date*

MonthDayYear
Date
Patient Consent for Use and Disclosure of Protected Health Information

I hereby give my consent for, Renata Flaks, DNP to use and disclose protected health information (PHI) about me to carry out treatment, payment and healthcare operations {TPO}. (Renata Flaks, DNP's Notice of Privacy Practices provides a more complete description of such uses and disclosures) I have the right to review the Notice of Privacy Practices prior to signing this consent. The practice reserves the right to revise its Notice of Privacy Practices at Renata Flaks, DNP's anytime. A revised Notice of Privacy Practices may be obtained by forwarding a written request to Renata Flaks, DNP. Privacy Officer at

Withthis consent, Renata Flaks, DNP may call my home, cell or other phone number listed on my chart and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and anything pertaining to my medical care, including laboratory test results among others. With this consent, Renata Flaks, DNP may mail to my home or other alternative locations listed on my chart any item that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements as long as they are marked Personal and Confidential. With this consent, Renata Flaks, DNP may e-mail me any items assist the practice in carrying out TPO, such as appointment reminder cards and patient statements. I have the right to request that Renata Flaks, DNP restrict how it uses or discloses my PHI to carry out TPO. However, the practice is not required to agree to my requested restrictions, but if it does, it is bound by this

By signing this form, I am consenting to Renata Flaks, DNP's use and disclosure of my PHI to carry out my TPO. I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent If I do not sign this consent, or later revoke it, Renata Flaks, DNP may decline to provide treatment to me.
Signature of Patient or Legal Guardian*

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Print Name of Patient or Legal Guardian*
Date*

MonthDayYear
Date
Patient or POA*
Please be advised although your insurance company has authorized services this is not a guarantee of payment If your insurance company denies those services you will be responsible for payment. Please initial:*
I have been advised that if Quality Dermatology does not accept my secondary insurance I will be responsible for any remaining balance after my primary insurance.(Please initial)*
It is my responsibility to obtain a referral if it is required by my insurance. If I fail to provide a valid referral at the time of service and my insurance denies my bills for lacking referral/authorization, I will be responsible for payment in full to Quality Dermatology. Please initial:*
I have been advised that Quality Dermatology sends all specimens to labs of practice choice If patients insurance is associated with specific labs it is patients responsibility to inform Quality Dermatology of their labs before the appointment Please initial*
Patient or POA Signature*

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Date*

MonthDayYear
Date
Select all that apply:

Benign MolesSeborrheic keratosis that are non-irritatedBrown spotsSkin TagsMilliumComedone extraction and blackhead removalHemangiomasOther
This is an elective procedure for cosmetic purposes, and is therefore non-reimbursable by insurance, or under Medicare.

Payment for the above procedure or procedures is required at the time of service. Our regular fees will be used for the services.
I understand and agree to the above. Print name:*
Signature*

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Date*

MonthDayYear
Date
QUALITY MEASUREMENTS: For patients 65 and older
Name of patient
Have you received a pneumonia vaccination?

YesNo
If not, was the reason medical?

YesNo
State the medical reason:
Do you have a living will?

YesNo
Do not intubate?

YesNo
Do not resuscitate?

Yes
Full Cardiopulmonary Resuscitation?

Yes
Do you have a health care proxy if you are unable to make your own medical decisions?

YesNo
If yes, what is their name and telephone number?
IV Drug Use?

YesNo
Drug use within past 12 months?

YesNo
Alcohol use?

YesNo
MEN ONLY: 5 or more drinks per day?

YesNo
WOMEN ONLY: 4 or more drinks per day?

YesNo
NAME*
DATE*

MonthDayYear
Date
HEIGHT*
WEIGHT*
EMAIL*
example@example.com
CONSENT TO TREAT MINORS
By law, any child under the age of 18 years old cannot be seen by a doctor without consent from a parent or legal guardian. If the minor arrives with someone other than a parent or legal guardian, we must have written permission from the parent or legal guardian that this person has been appointed by you to act on your behalf. You may appoint anyone who is over the age of 18 years of age to be responsible for your child when you are unable to accompany them to their medical appointment.

Parent / Legal Guardian

You must be present at your child's initial visit with the completed parental consent below:
Patient Date of Birth:
Patient Name
PARENT / LEGAL GUARDIAN INFORMATION
Name
Last four digits of SS#:
Date of Birth

MonthDayYear
Date
Work Phone:
Relationship to Patient
Cell Phone:
SPECIAL PERMISSIONS: This agreement is required in order for the minor child to be seen and treated without the parent/legal guardian present.
ACCOMPANIED BY OTHERS: If I am unable to accompany my child to the appointment, the below listed individuals have my permission to accompany my child and make medical decisions regarding my child. Please initial:
OTHER INDIVIDUALS ALLOWED TO ACCOMPANY MINOR:
Name:
Date of Birth:
Relationship to Parent:
CONSENT TO TREAT MINOR:

• I authorize QUALITY DERMATOLOGY to treat and provide any healthcare services to my child deemed necessary fortreatment and/or diagnosis.

• I also understand that, in the course of that treatment, photographs may be taken for clinical or educational purposes.

• I acknowledge that this consent will remain in effect until I revoke it in writing and present this document to the office or theminor reaches the age of 18 years.

By signing below, I certify that I have read the above information and have had any questions answered. My signature also certifiesmy understanding and agreement with the above information.
Parent/Legal Guardian Signature:

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Date

MonthDayYear
Date
Should be Empty:

Stents
Organ Transplant
Heart Murmur
Mitrovalve Prolapse
Anxiety
Hearing Loss
Arthritis
Hepatitis
Asthma
Hypertension
Atrial Fibrillation (Irregular Heartbeat)
HIV/Aids
BPH (Benign Enlarged Prostate)
Hypercholesterolemia (High Cholesterol)
Bone Marrow Transplantation
Hyperthyroidism
Breast Cancer
Hypothyroidism
Colon Cancer
Leukemia
COPD
Prostate Cancer
Coronary Artery Disease
Radiation Treatment
Depression
Seizures
Diabetes
Stroke
End Stage Renal Disease
GERD
Other
None

New Patient Form

QUALITY MEASUREMENTS: For patients 65 and older

CONSENT TO TREAT MINORS