Fillable DIRECTIONS 500 Commack Road Suite#102 Commack, NY 11725 (Academic medical center at State University of New York at Stony Brook)

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DIRECTIONS 500 Commack Road Suite#102 Commack, NY 11725 (Academic medical center at State University of New York at Stony Brook)

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BROWSE ACADEMIC MEDICAL CENTER AT STATE UNIVERSITY OF NEW YORK AT STONY BROOK FORMS

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DIRECTIONS
500 Commack Road Suite#102
Commack, NY 11725
Directions to our office can be obtained by calling our main number @ 631-444-4200 and pressing
option 5.
From the LIE (Long Island Expressway)
take exit 53 toward Bayshore/Kings Park. Keep right to
take the ramp towards Kings Park. Merge onto Sagtikos Parkway North. Take exit SM1W toward
New York. Merge onto Northern State Parkway West. Take County Highway 4 exit 43 toward
Commack. Turn left onto Commack Road and turn right into the parking lot by the Stony Brook
street sign.
From the Northern State Parkway take to County Highway 4 exit 43 toward Commack. Turn left
onto Commack Road and turn right into the parking lot by the Stony Brook street sign.
From 347 (Nesconset Highway) travelling West stay straight to go onto Northern State Parkway
West. Take County Highway 4 exit 43 toward Commack. Turn left onto Commack Road and turn
right into the parking lot by the Stony Brook street sign.
From Sunrise Highway take the Robert Moses Parkway ramp North. Take the exit towards East
Islip. Keep left at the fork and merge onto Southern State Parkway East. Keep left to take Sagtikos
Parkway North via exit 41A toward Kings Park. Take exit SM1W toward New York. Merge onto
the Northern State Parkway West. Take the County Highway 4 exit 43 toward Commack. Turn left
onto Commack Road and turn right into the parking lot by the Stony Brook street sign.
From Southern State Parkway take exit 41A Sagtikos Parkway North towards Kings Park. Take
exit SM1W toward New York. Merge onto Northern State Parkway West. Take County Highway 4
exit 43 toward Commack. Turn left onto Commack Road and turn right into the parking lot by the
Stony Brook street sign.
Name: _____________________________ DOB: _____________
STONY BROOK DERMATOLOGY ASSOCIATES
REASON FOR VI
SIT: __________________________________________________________
WEIGHT_________ HEIGHT_________
ALLERGIES______________________________________________________________________
DO YOU FEEL WELL TODAY? YES NO
o If no what are your symptoms
ARE YOU HAVING ANY PAIN? YES NO
o If yes, please tell us your pain level from 0-10 (0=none, 10 = worst)
o What is your pain tolerance (threshold)?
NO
WHAT IS YOUR PRIMARY LANGUAGE?_____________________
BARRIERS TO LEARNING: i.e.: impaired vision, hearing, reading or speaking YES
o If yes, pl
ease explain
PATIENT/PARENT LEARNING PREFERENCES (Please check at least one)
DEMONSTRATION EXPLANATION
PRINTED MATERIALS VIDEO WEB BASED
DO YOU PR
EFER SOMEONE PRESENT DURING TEACHING? YES NO WHO __________
DO YOU HAVE CULTURAL/RELIGIOUS PRACTICES THAT AFFECT PROVISION OF YOUR
HEALTHCARE? YES NO If yes please explain __________________________
DO YOU HAVE TROUBLE WALKING OR STANDING? YES NO
HAVE YOU FALLEN IN THE PAST 12 MONTHS YES NO
DO YOU HAVE A FEAR OF FALLING YES NO
WHEN WAS YOUR LAST INFLUENZA VACCINE?
NAME
DOSE
HOW MANY TIMES A DAY
TAKEN
Please list your MEDICATIONS or provide copy- If you need additional space please add to end of sheet.
(If none, please indicate "none")
Name: _____________________________ DOB: _____________
DO YOU USE TOBACCO YES NO
HAVE YOU EVER USED TOBACCO YES NO
DO YOU USE ALCOHOL YES NO
o How much
DO YOU FEEL SAFE AT HOME YES NO
DO YOU HAVE A FAMILY HISTORY OF:
NO
___ MELANOMA Who/Type? _____________
___ OTHER TYPES OF SKIN CANCER Who/Type? _____________
___ ANY CANCERS Who/Type? _____________
___ Other skin diseases & Who/Type?
HAVE YOU EVER BEEN DIAGNOSED WITH MELANOMA? YES NO
HAVE YOU EVER BEEN DIAGNOSED WITH ANY OTHER TYPE OF SKIN CANCER? YES
LIST ALL MEDICAL PROBLEMS (If none, please indicate "none")
o Heart valve problems: Yes No
o Artificial joints: Yes No
o Hepatitis: Yes No
o Pacemaker/Defibrillator: Yes No
o Do you need antibiotics before procedures? Yes No
LIST ANY PROCEDURES (If none, please indicate "none")
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
E-Prescribing Consent Form
Patient’s Name __________________________________ Date of Birth: ____________________
Stony Brook Dermatology Associates, UFPC is in the process of implementing e-Prescribe (electronic prescribing) in
our ongoing efforts to maximize patient safety.
Total Quality in patient care is just one of our ongoing commitments…
Patient benefits:
• Less confusion over handwritten prescriptions or unclear phone calls
• Reduced possibility of medical errors
• Less chance of adverse drug reactions
• Fewer trips to drop off at the pharmacy
• A safer, faster & easier way to get your prescription filled
_______________________________________
_______________________________________
Please list any DRUG allergies:
___________________________________
____________________________________
____________________________________
_______________________________________
Please provide our office with your pharmacy name (s), address & phone number so that we may enter this data into
your medical record.
Patient Consent:
I agree that Stony Brook Dermatology Associates, UFPC may request and use my prescription medication history
from other healthcare providers or third party pharmacy benefit payers for treatment purposes. This consent form
will be updated on an annual basis.
_____________________________________
Patient Signature Date
Pharmacy Name (1
st
Choice):
_____________________________________
Street Name, Town OR ZIP CODE:
_____________________________________
Ph#: ________-_________-__________ (if known)
Fax#: ________-_________-__________
Pharmacy Name (2
nd
Choice):
_____________________________________
Street Name, Town OR ZIP CODE:
_____________________________________
Ph#: ________-_________-__________ (if known)
Fax#: ________-_________-__________
COMMUNICATION CONSENT
STONY BROOK DERMATOLOGY
500 Commack Rd
Suite 102
Commack, NY 11725
It is the policy of Stony Brook Dermatology not to release confidential information other
than face to face without authorization to do so by alternative methods (Voice
Mail/Answering Machine/Telephone). Any information that will be provided will be
released only to the authorized person (s) listed below.
I authorize Stony Brook Dermatology, and/ or their staff to leave medical information
pertaining to my care by the following methods and will assume responsibility to notify
them whenever this information changes (please fill out all contact information).
Home Telephone: _______-_______-_______ YES ____ NO____
Answering Machine: YES ____ NO ____
Work Telephone: _______-_______-_______ YES ____ NO ____
Cell/ Voice Mail: _______-_______-_______ YES ____ NO ____
E-mail: _____________________@_________.com YES ____ NO ____
Regular Mail: YES ____ NO ____
If you would like to have information released to someone other than yourself, please
complete the following list of authorized people:
Spouse: ________________________________ Tel: _______-_______-_______
Adult Child: _________________________________ Tel: _______-_______-_______
Other (please indicate relation): _____________________Tel: _______-_______-_______
Print Patient Name: ________________________Preferred Tel: _______-_______-_______
Patient Signature: _______________________________
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DIRECTIONS 500 Commack Road Suite102 Commack, NY 11725 (Academic medical center at State University of New York at Stony Brook)

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Completed 27 August 2020

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