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Patient Registration Form

Patient Information

Employer Information

Referred By

Insurance Information

Subscriber Information

Policyholder if different from patient
I authorize the release of any medical information necessary to my insurance and/or CMS & its agents to process my insurance claim(s). I authorize payment of benefits directly to physicians on my behalf. I agree that this authorization will cover all medical services rendered until such authorization is revoked by me. I agree that a photocopy of this form may be used in lieu of the original. I agree to pay all charges not covered or later determined to be ineligible by my insurance carrier(s). These charges include but are not limited to deductibles, coinsurance, and copayment on my insurance policy. If the doctor is not participating with my insurance or I have not obtained the proper insurance referrals and authorizations, I am responsible for the bill for all services rendered.

Health History


Other:

Other:

Other:

Do you wear sunscreens?
Yes
No
If yes, spf
Do you have a family history of melanoma?
Yes
No
If yes, which relative:
Any other family history of skin disorders?


Symptoms Yes No
Itching
Irritated Skin Lesion
Changing Mole
Rash
Problem with healing
Problem with bleeding
Fevers
Chills
Abdominal pain
Joint aches
Sore throat
Thyroid problems
Immunosuppression
Shortness of breath
Anxiety
Depression
Chest pain
Symptoms Yes No
New or changing mole
Latex allergy
Allergy to adhesive
Allergy to Lidocaine
Allergy to topical antibiotic ointments
Artificial heart valve
Artificial joints within past two years
Blood thinners
Defibrillator
MRSA
Pacemaker
Premedication prior to procedures
Rapid heart beat with epinephrine
Pregnancy or planning a pregnancy