Fillable Divorced Widowed us Marital Stat : Single Married

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Divorced Widowed us Marital Stat : Single Married

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File type: PDF

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PATIENT ACCOUNT NUMBER
Phys:
Rec’d by:
PATIENT INFORMATION (Please Print) Today’s Date ____/____/____
Name
Last First M.I.
Address
Street Apt # City State Zip
Home Phone ( )
Cell Phone ( ) Work Phone ( )
Email
Address__________________________________ S.S. #
Marital Stat
us
: Single Married Separated
Date of Birth _____/______/_____ Age______ Sex______
Divorced Widowed
Employer
Address
Acco
mpanying Parent (if minor) ______________________________________________________________________
SUBSCR
IBER INFORMATION
Name
Last First M.I
.
Address
City State Zip
Home Phone ( ) Cell Phone ( ) Work Phone ( )
E
mployer
Address
Date of Birth _____/______/_____ Sex_________ S.S.#
INSURANCE INFORMATION
(Please present insurance card at time of check-in.)
Primary Insurance Name Secondary Insurance Name
Ins. Address
Ins. Address
Policyholder
Policyholder
Insured’s ID# Grp # Insured’s ID# Grp #
SS # Date of Birth____/____/____ SS # Date of Birth____/____/____
Relationship of patient to the Insured
Relationship of patient to the Insured
Insured Employer Name Insured Employer Name
Insured Employer Address Insured Employer Address
Insured Employer Phone ( ) Insured Employer Phone ( )
PHARMACY of CHOICE PHONE ( )
ADDRESS
Referring Doctor Family Doctor
Address
Address
Phone
Phone
I authorize the release of medical information to my primary care or referring physician, to consultants, if needed, and as necessary to
process insurance claims, insurance applications and prescriptions. I also authorize payment of medical benefits to physician.
In order to establish optimal relations with patients and avoid misunderstanding and confusion regarding our payment policies, our
staff is trained to consistently inform you of the financial payment policies of this office. Payment is required for all services at the
time they are rendered unless you are in a prepaid plan in which we participate. For these patients, applicable copayments and
deductibles will be collected at the time of service. We accept payment in the form of cash, check or credit card. If your insurance
plan denies payment, you will be responsible for payment to our office. In the event that your check is returned “insufficient
funds” or your account must be turned over to collections, a $30.00 administrative fee will be added to your account. Your
signature below signifies your understanding and willingness to comply with this policy.
Signature / Guardian Date / /
03.
08.17
MEDICAL INFORMATION
Patient Name Date of Birth Date
DESCRIBE CURRENT SKIN CONDITION
PAST/FAMILY/SOCIAL HISTORY
1) Have you had skin cancer? NO YES WHERE/WHICH TYPE?
2) Do any family members have/had skin cancer? NO YES WHICH TYPE?
3) Have you recently been hospitalized or spent time visiting in a hospital? NO YES EXPLAIN
4) Do you wear sunscreen? NO YES
5) Do you spend much time with your hands in water? NO YES
6) Do any family members have the condition for which you are seeing us today? NO YES WHO?
7) Do you or any family members have seasonal allergies or asthma? NO YES RELATIONSHIP
8) Do you work outdoors, spend a significant amount of time in the sun or use a tanning bed? NO YES
9) Do you drink alcohol? NO YES SOCIAL EXPLAIN
10) Do you smoke? NO YES IF SO, HOW MUCH
11) Do you have an advanced directive? NO YES
REVIEW OF SYSTEMS
Heart Problems
Thyroid Disease
H/O Drug or ETOH Dependency
Pacemaker/Defibrillator
Kidney Disease
Hepatitis-type
High Blood Pressure
Venereal Disease
Scar Easily
Heart Valve/Stent
Arthritis
Seasonal Allergies
High Cholesterol
Cold Sores
Emphysema
Easy Bleeding
Poor Healing
Asthma
Lupus
Artificial Joints/Replacements- type and year
Glaucoma
Currently Pregnant
LIST OTHER CURRENT MEDICAL PROBLEMS:
MEDICATION
Have you taken any ASPIRIN, PLAVIX, COUMADIN, PERSANTINE, HEPARIN, MOTRIN, ADVIL, FISH OIL or other pain relievers or
Arthritis medications in the last TWO weeks? NO YES Please List:
Do you require premedication before surgical procedures? NO YES
MEDICAL ALLERGIES AND REACTION:
CURRENT MEDICATIONS (include OTC and Herbal):
PHARMACY OF CHOICE: PHONE #: FAX#
REFERRING DR: PHONE #: FAX#
Chart #
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Divorced Widowed us Marital Stat : Single Married

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Completed 17 June 2021

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