Dermatology Partners

Patient Information Sheet


Patient Information Sheet

Please bring your insurance card to your appointment.

Patient Name: Date of Birth: Gender

Address: City: State: Zip:  

Home Phone: Cell Phone: Work Phone:

Email:  


Emergency Contact:   Relationship:  

Phone Number:  

How did you hear about our practice?

 

Please give us the following information to facilitate our communication with your primary care physician:

Primary Care Name (first and last):   City:  

Pharmacy Name:   City: Phone:  

Primary Insurance: ID#: Group#:  

Cardholder Name: Cardholder D.O.B.: Relationship:  

Secondary lnsurance:   ID#: Group#:

Cardholder Name: Cardholder D.O.B.:   Relationship:  

I have been able to review the Dermatology Partners Notice of Privacy Practices (available in our office). This notice provides information about how Dermatology Partners may use and disclose my protected health information, what it's legal duties are regarding my protected health information, what my right s are regarding my protected health information, and how I can file a complaint about these privacy practices. I understand that if I have additional concerns, I may ask the HIPAA compliance officer at Dermatology Partners for clarification.

By signing below, I also hereby authorize my insurance benefits (if applicable) to be paid directly to Dermatology Partners, lnc. I realize that I am responsible for the payment of non-covered services, co-payments, and deductibles. I also authorize the release of pertinent information to insurance carriers.

Do you take Blood Thinners?

Defibrillator or Pacemaker?

 

   

Reason fortoday's visit (chief complaint):

Current or past medical problems:

General Health

  

Eyes

 

Ears/Nose/Throat/Mouth

 

Heart

 

Lungs

 

Stomach/Bowel

 

Kidneys

 

Arthritis/Muscles/Joints

 

Skin

 

Headaches/Seizures

 

Psychological disorder

 

Thyroid/Diabetes

 

Blood/Bleeding disorder

 

Allergic/lmmunologic

 

Females:
Are you pregnant?

Planning to become pregnant?
 

Family History (past family and social history):
Mother: living/ deceased   Age
Father: living/ deceased   Age
Number of your children:   age(s)  

Check the following that have occurred in your family:

Social History:
Do you live alone?

 
Do you drink alcohol?

Do you smoke?
  Frecuency:

Do you use recreational drugs?
Frecuency:  

Occupation:  
Hobbies/leisure activities:

Date:

 

Leave this empty:

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Dermatology Partners https://dermatologypartnersinc.com
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Document name: Patient Information Sheet
lock iconUnique Document ID: 62d9833f3d473fb5aedf9cd6719ee55061573d5f
Timestamp Audit
May 6, 2020 4:07 pm MDTPatient Information Sheet Uploaded by Dermatology Partners Inc - info@dermpartner.com IP 190.195.243.61