New Patient Forms
PATIENT

 

 

 












Fill-out your preferred method of contact








English
Other 


 
 

Other Race 


Hispanic or Latino
Not Hispanic or Latino
Unknown

  R  L

Name of Employer:

Family Physician or Referring Doctor

Address

How did you hear of DOSO?

 Friend / Family Member

 Referring Physician

 Yellow Pages

 Website / Internet


RESPONSIBLE PARTY INSURANCE POLICY HOLDER

If the patient is the responsible party/policy holder, please check here & omit Lines 1-C and 2-C

1 - A PRIMARY PLAN INFORMATION


Name of Primary Insurance Plan

B

 Self  Spouse  Child  Other
(Check Patient Relationship to Policy Holder)


Name of Primary Policy Holder


Date of Birth

C


Address of Primary Policy Holder


Phone. No.


Social Security No.

2 - A SECONDAY PLAN INFORMATION


Name of Secondary Insurance Plan

B

 Self  Spouse  Child  Other
(Check Patient Relationship to Policy Holder)


Name of Secondary Policy Holder


Date of Birth

C


Address of Secondary Policy Holder


Phone. No.


Social Security No.

IF YOU HAVE NO INSURANCE, PLEASE CHECK HERE 

 

It is the policy of this office that the parent accompanying a child for treatment will be held responsible for all bills. Please complete the following information if you are the accompanying parent.

YOUR NAME: 

ADDRESS: 

DOB:

SSN:

PHONE #:

What PHARMACY do you prefer to use?

MY SIGNATURE BELOW AUTHORIZES ALL OF THE FOLLOWING:

1. My consent for Dermatology of Southeastern Ohio, Inc. to bill my insurance carrier according to the information I have provided. I have provided the most current insurance infortion as well as the appropriate cards. I unsderstand that all balances are my responsibility, whether covered by insurance or not, including co-pays, co-insurance amounts, deductible amounts, and all patient responsibility amounts. If i am uninsured, I understand that I am responsible for payment of all charges for services provided.

2. My consent for Dermatology of Southeastern Ohio, Inc. to release medical information as needed to the insurance companies listed in my demographics, other providers involved in my care, and to any physician listed here:

3. My consent for Dermatology of Southeastern Ohio, Ivnc. to obtain my medication information from my pharmacy.

4. My consent for Dermatology of South eastern Ohio, Inc. to examine me and, if needed, render treatment after the provider explains it to me.

5. My consent for a skin biopsy if needed. I understand the provider will discss this with me in advance.

6. Acknowledgement of receipt of Notice of Privacy Practices (HIPPA).

7. My consent for Dermatology of Southeastern Ohio, Inc, to share, discuss my medical information and financial account with the following person(s).:

I HAVE READ AND UNDERSTOON ALL OF THE ABOVE ITEMS.


Signature


Date

Check relationship to Patient:

 Self

 Parent

 POA

 Other 


DERMATOLOGY OF SOUTHEASTERN OHIO, INC.

MEDICAL HISTORY QUESTIONNAIRE

We are transitioning to new Electronic Medical Records (EMR) and need your updated medical history for entry into the new system.

PATIENT NAME:  DATE OF BIRTH 

MEDICAL HISTORY: Please check any of the following medical conditions you currently have.

 Anxiety

 Arthritis

 Asthma

 Atrial Fibrillation (irregular heartbeat)

 Bone Marrow Transplant

 BPH

 Breast Cancer

 Colon Cancer

 COPD

 Coronary Artery DS

 Depression

 Diabetes

 End Stage Renal DS

 GERD (Reflux DS)

 Hearing Loss

 Hepatitis

 High Blood Pressure

 HIV / AIDS

 Hypothyroidism

 Leukemia

 Lung Cancer

 Lymphoma

 Prostate Cancer

 Radiation Treatment

 Seizures

 Stroke

 NONE


Other Conditions:


SURGICAL HISTORY: Please check any of the following surgeries you have had.

 Appendix (Appendectomy)

 Bladder (Cystectomy)

Breast:

 Mastectomy:  R  L

 Lumpectomy  R  L

 Reduction

 Implants

Colon:

 Cancer Resection

 Diverticulitis

 IBD (Inflam.Bowel Ds)

 Gallbladder (Cholecystectomy)

Heart:

 Coronary Artery Bypass  PTCA

 Mech. Valve Replacement

 Biological Valve Replacement

 Transplant

Joint Replacement:

 R Knee  L Knee

 R Hip  L Hip

Kidney:

 Kidney Stone Removal  Biopsy  Nephrectomy  Transplant

Ovaries:

 Endometriosis  Ovarian Cyst  Ovarian Cancer

Prostate:

 Prostatectomy (TURP)  Prostate Cancer  P. Biopsy

Skin:

 Melanoma

 Basal Cell Carcinoma

 Squamous Cell Carcinoma

 Spleen (Splenectomy)

 Testicles (Orchiectomy)

Uterus:

 Hysterectomy

 Fibroids

 Cancer

 Other:

 NONE

 

SKIN HISTORY: Have you had any of the following skin conditons?

 Acne

 Actinic Keratoses

 Asthma

 Basal Cell Carcinoma Site(s)

 Blistering Sunburns

 Dry Skin

 Eczema

 Flaking or Itchy Skin

 Hayfever/Allergies

 Melanoma Site(s)

 Poison Ivy

 Precancerous Moles

 Psoriasis

 Squamous Cell Carcinoma Sites(s)

 Other:

 Atypical Nevi

 Hemangiomas

 Seborrheic Keratoses

 Warts

DO YOU WEAR SUNSCREENS: 

 YES  NO

if "YES", what SPF? 

DO YOU TAN IN A TANNING BED? 

 YES  NO

 


FAMILY HISTORY: Do you have a Family History of MELANOMA? if "YES", which relative

 Mother

 Father

 Sister

 Brother

 Daughter

 Son

 Uncle

 Aunt

 Nephew

 Niece

 Grandmother

 Grandfather

 Grandson

 Grandaughter


OTHER FAMILY HISTORY OF SKIN CANCER: (Include relative & type of skin cancer if known)


MEDICATION LIST: Please list below all medications that you currently take. Include over-the-counter medications as well as herbals, supplements and vitamins


ALLERGY HISTORY: List below any MEDICATIONS that you are ALLERGI to.


List below any OTHER allergies that you have.

 Environmental

 Seasonal

 Foods

 Insects

Other 

SOCIAL HISTORY

ALCOHOL USE:

 None / Less than 1 drink a day

 1-2 drinks a day

 3 or more drinks a day

SMOKING HISTORY:

 Every-day smoker

How many per day?

 Some-day smoker

How many per  per

 day  wk  mo?

 Former smoker

 Never smoker

 Unknown if ever smoked

 Unspecified

Contact Us

Our Location

Office Hours
Monday: 8:00 AM - 4:00 PM
Tuesday: 8:00 AM - 4:00 PM
Wednesday: 8:00 AM - 4:00 PM
Thursday: 8:00 AM - 4:00 PM
Friday: 8:00 AM - 4:00 PM
Saturday: Closed
Sunday: Closed