Fill-out your preferred method of contact
Date of Birth
Social Security Number
White Black or African Amer.
Asian Amer. Indian or Alaskan Native
Native Hawaiian / Other PacificIslander
Hispanic or Latino
Not Hispanic or Latino
Dominant Hand: R L
Name of Employer:
Family Physician or Referring Doctor
How did you hear of DOSO?
Friend / Family Member
Website / Internet
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
Self Spouse Child Other
(Check Patient Relationship to Policy Holder)
Name of Primary Policy Holder
Date of Birth
Address of Primary Policy Holder
Social Security No.
2 - A SECONDAY PLAN INFORMATION
Name of Secondary Insurance Plan
Name of Secondary Policy Holder
Address of Secondary Policy Holder
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.
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.
Check relationship to Patient:
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.
Atrial Fibrillation (irregular heartbeat)
Bone Marrow Transplant
Coronary Artery DS
End Stage Renal DS
GERD (Reflux DS)
High Blood Pressure
HIV / AIDS
SURGICAL HISTORY: Please check any of the following surgeries you have had.
Mastectomy: R L
Lumpectomy R L
IBD (Inflam.Bowel Ds)
Coronary Artery Bypass PTCA
Mech. Valve Replacement
Biological Valve Replacement
R Knee L Knee
R Hip L Hip
Kidney Stone Removal Biopsy Nephrectomy Transplant
Endometriosis Ovarian Cyst Ovarian Cancer
Prostatectomy (TURP) Prostate Cancer P. Biopsy
Basal Cell Carcinoma
Squamous Cell Carcinoma
Basal Cell Carcinoma Site(s)
Flaking or Itchy Skin
Squamous Cell Carcinoma Sites(s)
DO YOU WEAR SUNSCREENS:
if "YES", what SPF?
DO YOU TAN IN A TANNING BED?
FAMILY HISTORY: Do you have a Family History of MELANOMA? if "YES", which relative
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.
None / Less than 1 drink a day
1-2 drinks a day
3 or more drinks a day
How many per day?
How many per per
day wk mo?
Unknown if ever smoked