New patient form

PLEASE GIVE US YOUR INSURANCE CARD TO BE PHOTOCOPIED Please print clearly
Patient’s name: _________________________________________________________ Date: ______________________________________ Address:_______________________________________________________________ Home phone: ________________________________ City: __________________________________________________________________ State: ___________ Zip: ______________________ Patient’s occupation: _____________________________________________________ S.S.#: ______________________________________ Employer:______________________________________________________________ Business phone: _____________________________ Employer’s address: _____________________________________________________ State: ___________ Zip: ______________________ Birthdate: __________________________ Age: ____________ Sex: _____________ Marital status: S M W D Sep (circle one) If married, name of spouse: ____________________________________________________________________________________________ Person responsible for payment: ____________________________________________ Relationship: ___________ Birthdate: ___________ Address of responsible person: _____________________________________________ State: ___________ Zip: ______________________ Whom may we thank for referring you to us? ______________________________________________________________________________ Family or personal physician: __________________________________________________________________________________________ Whom may we contact in case of emergency? _________________________________ Phone: _____________________________________ INSURANCE INFORMATION
(Please check appropriate line)
***We are participating with Medicare and Blue Shield; however, certain plans require patients to pay deductible, co-insurance or eligible services Insurance company name:_________________________________________________ Group no: ________________________Identification No: ________________________ Subscriber:_____________________________________________________________(name of person carrying insurance) Subscriber’s SSN (if other than patient): ______________________________________Subscriber’s birthdate: _________________________ Lab to use: _____________________________________________________________ BRIEF MEDICAL HISTORY
(Rash, Acne, Growth, Scalp, Hair, etc.)_______________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ When did you first notice this problem?_______________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ Please indicate on the figures here where your present skin problem is by marking an “X” on the body sketch Yes Does your skin react to anything (tape, jewelry, perfume)? (For female patients only) Are you now pregnant? PLEASE ANSWER QUESTIONS ON REVERSE SIDE
Allergic reaction to Novocaine or Xylocaine? Blood transfusion within the past 10 years? Are you under the treatment of a doctor? _________________________________________________________ Reason: ___________________________________________________________________________________ MEDICINES
Has a doctor given you anything for your skin? If yes, please list t6he names of everything you have been given: ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ Have you put anything else on your skin yourself? (Non-prescription drugs, lotions, creams, etc.) Please list the names of everything you have used on it: _____________________________________________________________________________ Do you take any of the following? If so, give name of drug: Steroids? __________________________________________________________________________________ Aspirin or pain pills? _________________________________________________________________________ Nerve pills / sedatives? _______________________________________________________________________ Laxatives? _________________________________________________________________________________ Birth control pills? ___________________________________________________________________________ Anticoagulants (blood thinners)?________________________________________________________________ Please list all other medication that you are presently taking: ______________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ IN ORDER TO SUBMIT A CLAIM TO YOUR INSURANCE CARRIER, IT IS NECESSARY THAT THE PATIENT, OR PERSON ACTING ON HIS OR HER BEHALF, SIGN THE FOLLOWING AUTHORIZATION: “I AUTHORIZE ANY HOLDER OF MEDICAL OR OTHER INFORMATION ABOUT ME TO RELEASE TO MY MEDICAL INSURANCE CARRIER OR TO ITS INTERMEDIARIES, OR TO THE BILLING AGENT OF THIS PHYSICIAN OR SUPPLIER WHICH IS CHERYL D. ACKERMAN, M.D., ANY INFORMATION NEEDED FOR THIS OR A RELATED CLAIM. I PERMIT A COPY OF THIS AUTHORIZATION TO BE USED IN PLACE OF THE ORIGINAL, AND REQUEST PAYMENT OF MEDICAL INSURANCE BENEFITS EITHER TO MYSELF OR TO THE PARTY WHO ACCEPTS ASSIGNMENT.”

Source: http://www.mydermdoc.com/includes/NewPatientForm.pdf