PATIENT INFORMATION
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: _____________________________ |
GENE RAL MEDICAL HISTORY
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 ______
PAST COSMETIC HISTORY
Please place an ’X’ in front of any prior cosmetic procedures:
____Chemical Peels | ____Laser Resurfacing | ____BTX |
____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 DerbyDerm.com. 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 _____________________________________________