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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
____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 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   _____________________________________________     
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