Dermatology New Patient Form
Please fill out your form as completely and accurately as possible. Information collected on this form will only be used by TriState Health to register for your appointment unless stated otherwise and approved with your clear written consent.
Are you already an established patient at TriState Health?
*
Yes
No
Are you currently established with a primary care provider?
*
Yes
No
Please provide physician name.
Patient Information
Patient Name
*
First Name
Last Name
Previous/Maiden Name
Maiden Name
Social Security Number
Date of Birth
*
/
Month
/
Day
Year
Date
Sex
*
Please Select
Male
Female
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Phone Type
*
Please Select
Home
Cell
Work
Other
Alternative Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Alternative Phone Type
Please Select
Home
Cell
Work
Other
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Preferred Language
Race
*
Please Select
African American
Alaska Native
American Indian
Caucasian
Hispanic or Latino
Native American
Other
If other, what is your race?
Email
example@example.com
Do you have a Guarantor?
Yes
No
Guarantor
First Name
Last Name
Guarantor Relationship to Patient
Guarantor Date of Birth
/
Month
/
Day
Year
Date
Emergency Contact Information
Emergency Contact
First Name
Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Phone Type
Please Select
Home
Cell
Work
Other
Emergency Contact's Relationship to Patient
*
Insurance Information
PRIMARY INSURANCE INFORMATION
Primary Insurance
*
Primary Subscriber Name
*
Primary Subscriber's Relationship to Patient (If you are the primary subscriber, please write "self.")
*
Primary Subscriber's Date of Birth
*
/
Month
/
Day
Year
Date
Primary Insurance ID # (include alpha prefix, if applicable)
*
Primary Group #
*
Do you have secondary insurance?
Yes
No
SECONDARY INSURANCE INFORMATION
Secondary Insurance
*
Secondary Subscriber Name
*
Secondary Subscriber's Relationship to Patient (If you are the secondary subscriber, please write "self.")
*
Secondary Insurance ID #
*
Secondary Group #
*
Health Conditions/Concerns
Briefly describe your reason for visit (rash, acne, psoriasis, eczema, etc.)
*
Do you have a history of skin cancer, pre-cancer, or atypical moles?
*
Yes
No
Have you seen a dermatologist in the last 10 years?
*
Yes
No
Please provide physician name.
*
Before your first appointment, TriState must obtain your previous Dermatology medical records. Have you completed and submitted a Medical Records Release Form to your current provider's office?
*
Yes
No
Current and Past Medications
Are you currently taking any prescription or over-the-counter medications, skin related or otherwise?
*
Yes
No
Please list all current medications. Include all prescription and non-prescription (over-the-counter) medications, skin related or otherwise:
*
Have you taken any skin related medications in the past?
*
Yes
No
Please list all skin related skin medications taken in the past:
*
Pharmacy Preference
What is your pharmacy of choice?
Location (City, State)
Additional Information
Please leave any additional comments or information that you would like to share here:
Communication
Please read statement regarding TriState communications and choose one option.
I hereby authorize TriState Health to contact me via my provided email for TriState related marketing communications. Treatment is not conditioned upon my authorization to agree to receive marketing communication and my authorization shall remain effective until canceled by me in writing to TriState Health.
*
I agree
I do not agree
Market Research Questions
**OPTIONAL: Please answer one question below about how you heard about TriState Dermatology.
How did you hear about us? Please choose all that apply:
Word of Mouth
TV Commercial
Newspaper
Billboard
Magazine
Community Event
Facebook
Other
Please list below what other way you heard about us:
Submit
Should be Empty: