Step 1 of 5 0% Please note that it is important to fill in all the fields before submitting. Thank you.Patient InformationFirst Name* Middle Initial Last Name* Former Name (Maiden) Date of Birth* Sex* Male Female Social Security Number* Mailing Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Phone* Secondary Phone Work Phone Marital Status* Single Married Divorced Widowed Spouse Name Spouse Phone Number Your Email Address* Email Options I request online access to my health records Send me the bi-monthly e-newsletter Referred By: Insurance Provider Family/Friend Close To Home/Work Search Engine Doctor Emergency Contact InformationName* Relationship To Patient* Home/Cell Phone* Work Phone* Employer / Patient Guarantor EmployerName Work Phone Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code GUARANTOR / PERSON RESPONSIBLE FOR BILLPlease give your insurance card to the receptionist upon visit.Social Security Number Date of Birth Legal Name Relationship To Patient Self Spouse Domestic Partner Parent *If not self, please list information for the responsible party.Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home/Cell Phone Work Phone PRIMARY INSURANCE INFORMATIONName Of Insurance Company* ID Number* Name Of Insured* Date Of Birth* Patient Relationship To Subscriber* Self Spouse Domestic Partner Employer Child SECONDARY INSURANCE INFORMATION (If Applicable)Name Of Insurance Company ID Number Name Of Insured Date Of Birth Patient Relationship To Subscriber Self Spouse Domestic Partner Employer Child By checking below, I authorize the release of medical information to my primary care or referring physicians if needed and as necessary to process insurance claims, insurance applications and prescriptions whether by mail or by fax. I hereby release and discharge Southeastern Dermatology from all liability in connection with such release of information. I also authorize payment of medical benefits to the physician. I also understand that regardless of any insurance coverage I may have, I am responsible for any bills incurred and will be responsible for any charges associated with collecting this debt.While we will assist with billing your insurance company, you are primarily responsible for determining what your insurance will cover, whether you require a referral, and/or the payment of your bill.* Yes, I agree. Patient/Guardian Signature* Date* Month Day Year HISTORY INTAKE: Please note that it is important to fill in all the fields before submitting. Thank you.First Name* Middle Last Name* Date of Birth* Marital Status Single Married Partnered Divorced Widowed Preferred Language: English Spanish Indian Russian Race / Ethnicity: White Black or African American Hispanic American Indian Alaska Native Native Hawaiian Asian Choose not to answer Occupation & Workplace Place of Residence Height Weight Past Medical History: (please check all that apply) Anxiety Arthritis Asthma Atrial fibrillation Bone Marrow Transplant BPH Breast Cancer Colon Cancer COPD Coronary Artery Disease Depression Diabetes Kidney Disease GERD Hearing Loss Hepatitis(A / B / C) High Blood Pressure HIV/AIDS High Cholesterol Hyperthyroidism Hypothyroidism Leukemia Lung Cancer Lymphoma Prostate Cancer Radiation Treatment Seizures Stroke Irritable Bowel Syndrome Multiple Sclerosis Heart Attack Congestive Heart Failure Bleeding Disorder Lupus None Other Other past medical history:Past Surgical History: (please check all that apply) Appendix Removed Bladder Removed Mastectomy ( Right, Left, Both ) Breast Lumpectomy ( Right, Left, Both ) Breast Biopsy ( Right, Left, Both ) Breast Reduction Breast Implants Colectomy: Diverticulitis Gallbladder Removed Heart Bypass Angioplasty Heart Valve Replacement Heart Transplant Knee Replacement ( Right, Left, Both ) Hip Replacement ( Right, Left, Both ) Kidney Biopsy Kidney Removed ( Right, Left ) Kidney Stone Removal Kidney Transplant Ovaries Removed Prostate Biopsy Prostate Removed Skin Biopsy Basal Cell Surgery Squamous Cell Carcinoma Surgery Melanoma Surgery Spleen Removed Testicles Removed ( Right, Left, Both ) Hysterectomy None Other Skin Disease History: (please check all that apply) Acne Actinic Keratoses Asthma Basal Cell Skin Cancer Blistering Sunburns Dry Skin Eczema Flaking or Itchy Scalp Hay Fever/Allergies Melanoma Poison Ivy Precancerous Moles Psoriasis Squamous Cell Cancer None Other Other skin disease history:Do you wear Sunscreen? Yes No If yes, what SPF? Do you use a tanning bed? Yes No If yes, how often? Do you have a family history of Melanoma? Yes No If yes, which relative(s)?Other family history:Medications: (Please enter all current medications including vitamins and supplements)No Medications Not taking medications Allergies: (Please enter all allergies and type of reaction)No Allergies No known allergies Social History: (Please select all that apply) Not sexually active Sexually active w/ 1 partner Sexually active w/ more than 1 partner Same sex partner Drug use IV Drug Use Alcohol use: none Alcohol use: less than 1 drink per day Alcohol use: 1-2 drinks per day Alcohol use: 3 or more drinks per day Patient feels safe at home Patient feels unsafe at home Smoking Status: Current everyday smoker Current some day smoker Former smoker Never How often do you exercise: Several times per day Once a day A few times a week A few times a month Never Caffeine Use: Several times per day Once a day A few times a week A few times a month Never *Review of Systems: Are you currently experiencing any of the following? (please check yes/no for the following)Problems with bleeding* Yes No Problems with healing* Yes No Problems with scarring* Yes No Rash* Yes No Immunosuppression* Yes No Hay fever* Yes No Chest pain* Yes No Fever or chills* Yes No Night sweats* Yes No Unintentional weight loss* Yes No Thyroid problems* Yes No Sore throat* Yes No Blurry vision* Yes No Abdominal pain* Yes No Bloody stool* Yes No Bloody urine* Yes No Joint aches* Yes No Muscle weakness* Yes No Neck stiffness* Yes No Headaches* Yes No Seizures* Yes No Cough* Yes No Shortness of breath* Yes No Wheezing* Yes No Anxiety* Yes No Depression* Yes No *Medical Alerts: Which of the following apply to you? (please check yes/no for the following)Allergy to adhesive* Yes No Allergy to lidocaine* Yes No Allergy to topical antibiotics* Yes No Artificial heart valve* Yes No Artificial joints w/i past 2 years* Yes No Blood thinners* Yes No Defibrillator* Yes No MRSA* Yes No Pacemaker* Yes No Premed prior to procedures* Yes No Rapid heart beat with epinephrine* Yes No Pregnancy/Planning to be* Yes No Practice Data:Preferred Pharmacy Name: None Preferred No Preferred Pharmacy Primary care provider: No Primary care provider No Primary care provider Referring provider: Preferred Pharmacy Address: City: State: Zip Code: Patient/Guardian signature:* Date* MM slash DD slash YYYY FINANCIAL POLICY: Please note that it is important to fill in all the fields before submitting. Thank you.First Name* Middle Last Name* Thank you for choosing us as your health care provider. We are committed to your treatment being successful and your health is our greatest concern. The following is a statement of our Financial Policy, which we require that you read and sign prior to any treatment so that you understand your responsibility regarding the charges for services rendered by this office. All patients must complete and sign our Registration Form in full before seeing the physician. If you have insurance which will pay our physician directly, and which we can verify, we still require that all co-payments, deductibles, co-insurances and charges for non-covered/cosmetic services be paid for at the time service is rendered. We will file both your primary and secondary insurance. If you have Medicare as well as a secondary coverage that is not a Medigap, we will file a claim to your secondary carrier. If you are a member of an HMO or PPO which requires a referral form from your primary care physician, you are responsible for having the referral in our office prior to your appointment. Payment is due at the time of service. We accept cash, checks and credit cards. If needed, a payment plan can be established with prior approval from the practice manager. If you are unable to keep your appointment, kindly give a 24-hour notice. Please help us to serve you better by keeping scheduled appointments. If you are more than 15 (fifteen) minutes late for your appointment, you may asked to reschedule for another date. Thank you for understanding our Financial Policy. Please let us know if you have any questions or concerns. * I have read the Financial Policy and understand that I am responsible for all charges incurred by me. I agree to pay any monies due to Southeastern Dermatology Consultants, P.C. Patient/Guardian signature:* Date* MM slash DD slash YYYY HIPAA FORM: Please note that it is important to fill in all the fields before submitting. Thank you.First Name* Middle Last Name* I authorize Southeastern Dermatology Consultants, PC and its employees the following: (Please check Yes or No)Call to remind me of my appointment:* Yes No Text appointment reminders to my cell phone:* Yes No Leave a message at my home telephone number:* Yes No Contact me on my cell phone:* Yes No Call me at work and/or leave a message:* Yes No Contact me via email:* Yes No Place me on the monthly e-newsletter list:* Yes No Release information and/or test results to my physician:* Yes No Leave test/pathology results on my answering machine:* Yes No Give test/pathology results and/or discuss my care with:Name:* Relationship:* Name: Relationship: Email Address: * This authorization will remain in effect until I provide written instructions otherwise. Patient/Guardian signature:* Date* MM slash DD slash YYYY Patient Name DOB What is your current skin care regimen? Do you use sunscreen daily? (Y/N) Do you sunbathe or indoor tan? Are you applying any topical prescriptions or taking any prescription medication? What, if any, cosmetic procedures have you had in the past? Are you concerned about any of the following? Check all that apply. Fine Lines Brown Spots Melasma Broken Capillaries Dull or Rough Skin Sagging Skin Unwanted Hair Spider Veins Unwanted Tattoos Pore Size Lip Fullness Wrinkles Looking Tired Loss of Facial Volume Constant Angry or Mad Face Acne Scars Double Chin Belly Fat Stretch Marks Jowls Any other cosmetic concerns not listed? Any specific procedures you would like more information about? How did you hear about us? Is there anyone we can thank for referring you to our practice? Name First Last
