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Patient Registration Form
Patient Information
Last Name
First Name
Middle Initial
Street Address
State
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City
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Zip Code
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Social Security #
Phone number/other
Date of Birth
Sex
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Male
Female
Other
Cell Phone
Email
Marital Status
Select Marital Status
Single
Married
Widow
Divorced
Emergency contact & phone #
Pharmacy name and phone #
Employer Information
Name
Work Number
Occupation
Address
State
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Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
City
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Zip Code
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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
Select State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
City
Select City
Zip Code
Select 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
MEDICATION ALLERGIES
MEDICATION ALLERGIES
Cigarette smoking
Select
never smoked
Quit
never smoked
PAST MEDICAL HISTORY:
(Please check all that apply)
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:
PAST SURGICAL HISTORY
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:
SKIN DISEASE HISTORY
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?
MEDICATIONS:
(please list all your current medications)
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