Patient Registration

Patient Information

Last Name

First Name

Middle Initial

Street Address

State

City

Zip Code

Social Security #

Phone number/other

Date of Birth

Sex

Cell Phone

Marital Status

Emergency contact & phone #

Pharmacy name and phone #

Employer Information

Name

Work Number

Occupation

Address

State

City

Zip Code

Referred By

Referred by

Address

Phone #

Primary Care Physician

Address

Phone #

Insurance Information

Name of First Insurance Company

Insurance ID Number

Local/Group Number

Name of Secondary Insurance Company

Insurance ID Number

Local/Group Number

Subscriber Information

Policyholder if different from patient

Relationship to Patient

Name

Date of Birth

Social Security Number

Address

State

City

Zip Code

Phone Number

Employer's Name

Work Number

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

Reason for Today's visit

MEDICATION ALLERGIES

Cigarette smoking

Review of Symptoms: Are you currently experiencing any of the following?:
(Please check Yes or No)

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

Other Symptoms

Alerts: Are you currently experiencing any of the following? (Please check yes or no)

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

Other Symptoms

None	Colon Cancer	Hypertension	Radiation treatment
Anxiety	COPD	HIV/AIDS	Seizures
Arthritis	Coronary artery disease	High cholesterol	Stroke
Artificial joints	Depression	Hypothyroidism	Valve replacement
Asthma	Diabetes	Leukemia	Atrial fibrillation
End stage Renal disease	Lung cancer	Benign prostate enlargement	GERD
Lymphoma	Bone Marrow Transplant	Hearing loss	Pacemaker
Breast Cancer	Hepatitis	Prostate Cancer
Other:

None	Breast reduction	Heart valve replacement	Prostate removed
Appendix removed	Breast implant	Heart transplant	Prostate biopsy
Bladder removed	Colon removed	Joint replacement in past 2 years	TURP
Lumpectomy	Gall bladder removed	Kidney stone removal	Mastectomy
Breast biopsy	Coronary artery bypass	Kidney transplant
Other:

None	Dry Skin	Posion ivy	Acne
Eczema	Precancerous mole	Actinic keratosis	Flaky, itchy scalp
Psoriasis	Basal Cell cancer	Seasonal allergies	Squamous cell cancer
Blistering sunburns	Melanoma
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?

Patient Registration Form

Patient Information

Employer Information

Referred By

Insurance Information

Subscriber Information

Policyholder if different from patient

Health History