PATIENT DEMOGRAPHICS SHEET

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1 PATIENT DEMOGRAPHICS SHEET Patient Name: Parent/Legal Guardian Name: Date of Birth: Phone: Address: CITY STATE ZIP Social Security Number: Patient Phone: Sex: M F Home Cell Business Okay to leave detailed message with medical information? YES NO (Initial) Preferred Appointment Confirmation: Text Message Phone Call Employer: Work Phone: Primary Care Doctor (First & Last name): Primary Care Doctor s Phone: Who referred you to our practice: Primary Insurance Company: Self (If self insured, please only complete policy number and group number) Insured s Name: Relationship to Patient: Insured s SSN: DOB: Sex: M F Insured s Address: Insured s Phone Number: Policy Number: Employer: Group Number: Secondary Insurance Company: *Please inform front desk if you have a Secondary Insurance Policy Ethnic Background (optional): Race: Emergency Contact Name: Relationship: Preferred Language: Phone:

2 HIPAA AUTHORIZATION FORM Patient Name: Social Security #: Any physician, staff, employee or representative of Riverside Dermatology & Aesthetic Center, P.C. has my permission to discuss my account and medical conditions which may include symptoms, treatments, diagnosis, test results, medications or any other type of protected health information with the following persons in order to facilitate and coordinate my care, treatment, and payment: I understand that authorizing the release of my information to the above individual(s) is voluntary and does not affect my access to treatment. I can refuse to sign this form. I can revoke it by writing to Riverside Dermatology & Aesthetic Center, P.C. or completing a new form at any time. This authorization will remain in effect until I change or revoke it. I understand that if information is shared with the above individuals it may be subject to redisclosure by the individual(s). Patient s Printed Name Signature Date Legal Guardian/ Patient Signature Date Representative Printed Name Copy given to patient

3 INFORMED CONSENT FOR MEDICAL PHOTOGRAPHY Photographs are a necessary part of the patient s personal and permanent medical record. Photographs are used to identify patients, prevent patient fraud, identify lesion and biopsy locations, follow suspicious lesions over time, and provide a complete and objective description of a lesion and location. Photography is a valuable tool that is utilized by this medical practice to enhance the practice of medicine and improve patient care. It also reduces the risk of incorrect lesion or site removal and improves the efficiency and accuracy of the staff and providers. I understand that any photographs taken of me may be placed in my medical record for future treatment, electronically ed to my referring, treating, or consulting health professional, used by health professionals for education and training, and used in paper or electronic health publications. I understand that if a photograph of my skin lesion or condition is published in marketing materials or medical journals that it will be a non-identifiable photograph, and that my privacy will in no way have been compromised. By signing below, I confirm that I understand this consent form, have had any questions about medical photography answered, and am agreeing to have my photograph taken in the office and stored on their digital devices. Patient s Printed Name Signature Date Legal Guardian/ Patient Signature Date Representative Printed Name Witness Printed Name Witness Signature Date

4 PRIVACY NOTICE CONSENT CONSENTS, RELEASES, & ACKNOWLEDGMENTS Our Notice of Privacy Practices provides you with information about how we use and disclose protected health information about you. By signing below, you acknowledge that you have received a copy of our Notice of Privacy Practices. A copy is also posted in our waiting room for your convenience. PHYSICIAN ASSISTANT CONSENT GENERAL RELEASE This office utilizes the services and practice of a Certified Physician Assistant. The level of practice has been approved by the Georgia State Board of Medical Examiners. The Physician Assistant is under the supervision of the Physician, and is in good standing with the National Commission on Certification of Physician Assistants. Your signature on this page acknowledges that you are in agreement with being treated by a Physician Assistant. INFORMATION RELEASE I authorize the release and disclosure of any and all of my medical and treatment records or reports to any other health care provider who may be of assistance, in the opinion of Riverside Dermatology & Aesthetic Center, and/or for assisting in any reimbursement of medical benefits to which patient may be entitled. I further authorize and request that insurance payments be made directly to Riverside Dermatology & Aesthetic Center should they elect to receive such payment. This is a direct assignment of my rights and benefits under this policy. FINANCIAL RESPONSIBILITY ACKNOWLEDGMENT I acknowledge full financial responsibility for services rendered by Riverside Dermatology & Aesthetic Center. I understand that payment of charges incurred is due at the time of services unless other definite financial arrangements have been made prior to treatment. I agree to pay all reasonable attorney fees and collection costs in the event of default of payment of my charges. I have read and fully understand and agree to the above Consent of Treatment, Financial Responsibility, Release of Medical Information, and Insurance Authorization. Patient s Printed Name Signature Date

5 Name: DOB: MEDICAL INTAKE SHEET Social Security Number: Date: Preferred Pharmacy Name: Pharmacy Phone Number or Location: Primary Care Doctor (first & last name): Past Medical History: Please check if you have or have ever had any of the following. Anxiety Colon Cancer Hepatitis Lung Cancer Arthritis Coronary Artery Disease High Blood Pressure Lymphoma Asthma Depression HIV / AIDS Prostate Cancer Atrial Fibrillation Diabetes High Cholesterol Radiation Treatments Bone Marrow Transplant End Stage Kidney Disease Hyperthyroidism Seizures Benign Prostate Enlargement GERD / IBS Hypothyroidism Stroke Breast Cancer Hearing Loss Leukemia NONE OF THE ABOVE Please list any other medical problems: Please list all previous surgeries: Skin Disease History: Please check if you have or have ever had any of the following. Acne Blistering Sunburn Flaking/ Itching Scalp Precancerous Moles Actinic Keratoses Dry Skin Hay Fever/Allergies Psoriasis Asthma Eczema Poison Ivy Skin Cancer Unkown Basal Cell Carcinoma Squamous Cell Carcinoma Melanoma (list all affected & relationship) OTHER: NONE OF THE ABOVE Do you wear sunscreen? Yes No If yes, what SPF? Tanning Bed History: Never used Formerly used, but no longer use Currently use Please list (or attach) all your vitamins, supplements, and current medications (over the counter and prescription), and provide us with an updated list each visit: List any medication, food, or environmental allergies:

6 Social History: Do you currently smoke? Yes No Packs per day? for years Have you ever smoked? Yes No Packs per day? for years Cautions in Medical History: Please check all that apply. Artificial Joints (Joint Replacements) in past 2 years Artificial Heart Valve Coronary Artery Disease Planning Pregnancy Allergic to Adhesive Defibrillator Pregnant Allergic to Latex High Blood Pressure Pre-medicate prior to procedures Allergic to Lidocaine HIV / AIDS Prior Chemotherapy Allergic to Topical Antibiotics Low Blood Count Rapid Heart Beat with Epinephrine Blood Thinner Use Pacemaker Use Home Oxygen NONE OF THE ABOVE Family Medical History: Please check all that apply. Skin Cancer Unkown Basal Cell Carcinoma Squamous Cell Carcinoma Melanoma (list all affected & relationship) Psoriasis Eczema Seasonal Allergies Autoimmune Disease Lupus Thyroid Problems Asthma NONE OF THE ABOVE If your appointment concerns Acne, please check if you have had either of the following: Scarring Acne Isotretinoin (Accutane) Use 1. What is your reason for today s visit? TODAY S VISIT 2. Do you need any refills on medications or products? Yes / No If yes, which ones? 3. Have you had any major health changes since your last visit? Yes / No If yes, please explain: *Fill out information below if applicable* 4. How long have you had the problem you stated in #1? 5. What location(s) of your body is/are affected? 6. What symptom(s) do you have? i.e. itching, hurting, bleeding 7. Does anything make this problem worse? 8. Does anything make this problem better? 9. How does this affect your life? 10. Have you been evaluated for this problem before? Yes / No If so, what diagnosis was given? 11. Did you receive any treatment? Yes / No If yes, what was it? 12. Is there anyone else in your family with similar symptoms? Yes / No

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