Fillable SP SUTTON PLACE PATIENT INFORMATION

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SP SUTTON PLACE PATIENT INFORMATION

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The SP SUTTON PLACE PATIENT INFORMATION form is 4 pages long and contains:

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  • 86 check-boxes
  • 63 other fields

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File type: PDF

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city:STREET ADDRESS:
zip code:STATE:
city:STREET ADDRESS:
SUTTON PLACE
DERMATOLOGy
SP
PATIENT INFORMATION
femalemalesex:
OCCUPATION:
NAME OF EMPLOYER / SCHOOL:
SOCIAL SECURITY NUMBER:
DATE OF BIRTH:
BUSINESS / CELL PHONE:HOME / CELL PHONE:
"I am in agreement to pay statement In the event of insurance denial."
RECEIPT oF NOTICE OF PRIVACY practices
WRITTEN ACKNOWLEDGEMENT FORM
date:signature of patient:
date:PATIENT (OR AUTHORIZED SIGNATURE):
i, , have received a copy of Sutton Place Dermatology's
notice of privacy practices.
date:PATIENT (OR AUTHORIZED SIGNATURE):
phone:name:
zip code:STATE:
zip code:STATE:
city:STREET ADDRESS:
mARITAL STATUS (OPTIONAL):name:
REFERRING PHYSICIAN:ACCOUNT NUMBER:
OFFICE USE ONLY OFFICE USE ONLY
MUST PROVIDE EMERGENCY CONTACT
"I verify the accuracy of the above information and I authorize the release
of information as provided in the privacy policies i have read".
have you had a covid-19 vaccine? if yes, which one?:
date of first dose:
date of second dose:
click to sign
signature
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signature
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signature
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other:
other:
History and Intake Form
Past Surgical History: (please check all that apply)
Past Medical History: (please check all that apply)
Anxiety
Arthritis
Asthma
Atrial fibrillation
Bone Marrow Transplantation
Breast Cancer
Colon Cancer
COPD
Coronary Artery Disease
Appendix Removed
Bladder Removed
Mastectomy (Right, Left, Bilateral)
Lumpectomy (Right. Left, Bilateral)
Breast Biopsy (Right, Left, Bilateral)
Breast Reduction
Breast Implants
Colectomy: Colon Cancer Resection
Colectomy: Diverticulitis
Colectomy: IBD
Gallbladder Removed
Coronary Artery Bypass
Mechanical Valve Replacement
Biological Valve Replacement
Heart Transplant
Joint Replacement, Knee (Right, Left, Bilateral)
Thyroid Problems
Leukemia
Lung Cancer
Lymphoma
Prostate Cancer
Radiation Treatment
Seizures
Stroke
none
High Cholesterol
Depression
Diabetes
End Stage Renal Disease
GERD
Hearing Loss
Hepatitis
High Blood pressure
HIV/AIDS
Joint Replacement, Hip (Right, Left, Bilateral)
Joint Replacement within last 2 years
Kidney Biopsy (Nephrectomy)
Kidney Removed (Right, Left)
Kidney Stone Removal
Kidney Transplant
Ovaries Removed: Endometriosis
Ovaries Removed: Cyst
Ovaries Removed: Ovarian Cancer
Prostate Removed: Prostate Cancer
Prostate Biopsy
TURP (Prostate Removal)
Spleen Removed
Testicles Removed (Right, Left Bilateral)
Hysterectomy: Fibroids
Hysterectomy: Uterine Cancer
none
Social History: (Please circle all that apply)
Allergies: (Please enter all allergies)
Medications: (Please enter all current medications)
If yes, which relative(s)?
If yes, what SPF?:
Do you have a family history of Melanoma?
noyes
Do you tan in a tanning salon?
noyes
Do you wear Sunscreen?
noyes
Do you wear Sunscreen?
other:
Skin Disease History: (please check all that apply)
Acne
Actinic Keratoses
Asthma
Basal Cell Skin Cancer
Blistering Sunburns
Poison Ivy
Precancerous Moles
Psoriasis
Squamous Cell
Skin Cancer
none
Dry Skin
Eczema
Flaking or Itchy Scalp
Hay Fever / Allergies
Melanoma
noyes
Ethnic Group:
City or Zip code:
Preferred pharmacy name:
phone:
Race:
Preferred Language:
other:
Family History (Only first degree relatives)
Social History: (Please circle all that apply)
EtOH - None
EtOH - less than 1 drink per day
EtoH - 1 - 2 drinks per day
EtOH - 3 or more drinks per day
Alcohol Use:
Currently Smokes
Has smoked in the past
Never smoked
Former Smoker
Cigarette Smoking:
Please allow 24 hours for any appointment cancellations or there will be
a non-cancellation fee of $50.
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SP SUTTON PLACE PATIENT INFORMATION

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Completed 1 February 2022

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