NEW PATIENT INTAKE FORM

How did you hear about us?

Patient's Name

First NameLast Name

Date of Birth

Date

Social Security Number

Gender

Marital Status

Race

Ethnicity

Home Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Cell Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Work Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Preferred Phone

Is it OK to leave a detailed message?

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

Format: (000) 000-0000.

IV Drug Use?

IV Drug Use within past 12 months?

Alcohol Use?

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

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)

Do you wear sunscreen?

Do you tan in a tanning salon?

Family History of Melanoma?

If yes, which relative?

MEDICATIONS (Please list or give to front desk)

Any allergies to medications?

If Yes, what medications?

FEMALES ONLY: Date of last menstrual period?

FEMALES ONLY: Menopausal?

Smoking History:

Please select any of the following that are applicable:

Are you your own Power of Attorney?

REASON FOR YOUR VISIT TODAY?

Do you give consent to electronically update medication list from your pharmacy?

Do you give consent to update your patient portal?

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

Today's Date

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

Print Name of Patient or Legal Guardian

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

Date

Select all that apply:

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

Date

Name of patient

Have you received a pneumonia vaccination?

If not, was the reason medical?

State the medical reason:

Do you have a living will?

Do not intubate?

Do not resuscitate?

Full Cardiopulmonary Resuscitation?

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

If yes, what is their name and telephone number?

IV Drug Use?

Drug use within past 12 months?

Alcohol use?

MEN ONLY: 5 or more drinks per day?

WOMEN ONLY: 4 or more drinks per day?

NAME

DATE

Date

HEIGHT

WEIGHT

EMAIL

example@example.com

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

Date

Work Phone:

Format: (000) 000-0000.

Relationship to Patient

Cell Phone:

Format: (000) 000-0000.

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:

Date

New Patient Form

QUALITY MEASUREMENTS: For patients 65 and older

CONSENT TO TREAT MINORS

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