Our Location
MRN
Date:
Last Name
First Name
MI
Title
Street Address
City
State
ZipCode
Home Phone
Cell Phone
E-mail Address
Fill-out your preferred method of contact
Gender MaleFemale
Marital Status Select OneMarriedSingleDivorcedWidowed
Student Status
Date of Birth
Age
Social Security Number
Language: English Other
Race: White Black or African Amer. Asian Amer. Indian or Alaskan Native Native Hawaiian / Other PacificIslander Other Race
Ethnicity: Hispanic or Latino Not Hispanic or Latino Unknown
Dominant Hand: 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
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
C
Address of Primary Policy Holder
Phone. No.
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.
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
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:
Acne
Actinic Keratoses
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)
Atypical Nevi
Hemangiomas
Seborrheic Keratoses
Warts
DO YOU WEAR SUNSCREENS:
YES NO
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
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
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