This is a confidential record and will be kept in your chart only. 
Information will not be released without your authorization.

Today’s Date: ____/_____/__________       Name: ____________________________________________   

E-mail: __________________________________________         Birth Date: ______/_____/___________ 

Address: _________________________________     City/State __________________     Zip __________

Home Phone (       ) ______-_________    Cell (       ) ______-_________      Alt (       ) ______-_________

To receive text appointment confirmations and reminders on your cell please provide the name of your

carrier such as Verizon, AT&T, Sprint, T-Mobile… ___________ Preferred method of contact ___________

Occupation: ______________________         Employer/School: ____________________ Circle:   Male/Female       

Employed/Full-time Student/Part-time Student          SSN __ __ __ - __ __ - __ __ __ __

How did you hear of us? Friend/ Family, Newspaper, Internet, Billboard, Dr. Referral, Best of KS, Insurance Co, TV

If filing insurance: Policy holder (if not patient) ___________________ SSN __ __ __ - __ __ - __ __ __ __
Policy holder's date of birth _____ / _____/ _____ Policy holder’s Phone:  (       ) ______-___________
Policy holder’s  Address:  _____________________ City/State: ____________________ Zip __________
Policy holder's Relatinship to patient: ____________ Reason for visit: _____________________________


Within the last year, have you been under a provider’s care? No ______ Yes ______
Within the last year, have you been under a dermatologist care? No ______ Yes ______
Within the last year, have you undergone any surgery?   No ______ Yes ______

If yes to any of the above please specify __________________________________________

Have you had any of these health problems in the past or present? (circle all that apply)

Asthma Arthritis Autoimmune disorder High Cholesterol
Blood Disorder Chest Pain Clotting Disorder Thyroid Disorder
Colon Problems Diabetes Depression Digestive Problems
Easy Bruising Excessie Scarring Excessive Bleeding Heart Attack
Heart Disease High Blood Pressure Hepatitis HIV / AIDS
Hormone Imbalance Irregular Heart Beat Intestional Problems Kidney Disease
Liver Disease Lung Disease Mental Disorder Multiple Slerosis
Muscular Dystrophy Mitral Valve Prolapse Migraines Neuromuscular Disease
Pheumatic Fever Shortness of Breath Seizures Stroke

If you have a history of high blood pressure, what is your typical pressure? ______ / ______

If you have a history of diabetes, are you insulin dependent? Yes ______ No ______

Are you allergic to Latex? Yes ______ No ______ Do you wear contact lenses? Yes ______ No ______

Social History: Do you smoke or use any form of tobacco? Yes ______ No ______

Allergies: (list meds and reaction.) _____________________________________________________________________________


List your current medications: (prescribed / OTC / herbals / supplements): _____________________________________________


Are you currently using any blood thinners? (Aspirin, NSAIDS, Coumadin, Plavix...) Yes ______ No ______

Please place an ’X’ in front of any prior cosmetic procedures:

____Chemical Peels ____Laser Resurfacing ____Botox
____Laser Hair Reduction ____ Laser Vein Treatment ______Intesnse Pulse Light Rejunation
____Microdermabrasion ____Sclerotherapy ____Fillers (Collagen, Restylane, Radiesse)

Have you had any reaction to the following? (Circle all that apply)

Cosmetics Medicine Iodine Pollen Food Animals Fragrances
Sunscreens Rubbing Alcohol Soy Lidocaine Ephiepherine Paper-Tape Hydroxy acids

The information on this form is correct to the best of my knowledge.  With my consent, Derby Derm may use and disclose Protected Health Information about me to carry out Treatment, Payment and Healthcare Operations.  Please ask to see the Notice of Privacy Practices (HIPPA) for a more complete description of such uses and disclosures.  With this consent, Derby Derm may call or send information to carry out Treatment, Payment and Healthcare Operations, such as appointment reminders, insurance items pertaining to my clinical care, including laboratory results.   If a referral is needed it is my responsibility to obtain it prior to my visit.  I understand that medically necessary services may be reimbursed by insurance but aesthetic services are generally not and all costs are my responsibility.

 Patient (or Guardian) Signature   _____________________________________________

Cancellations    At Derby Derm your appointment is scheduled with a professional, whose time is allocated exclusively for your scheduled treatment.  Appointments cancelled or rescheduled within 24 hours of the scheduled time will be charged a cancellation fee of $25 by credit card or invoice.  If you need to cancel or reschedule an appointment, you must notify Derby Derm at least 24 hours prior to your appointment.  For your convenience you may now schedule or reschedule appointment through our website, please visit By signing below you agree to our cancellation policy and agree to allow us to charge your credit card on file or be invoiced for such charges.  

Patient (or Guardian) Signature   _____________________________________________