How did you hear about our services? (Check ONE only)

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1 Name: of Visit: Is your visit a MEDICAL or COSMETIC visit? (Check one) How did you hear about our services? (Check ONE only) 1. Newspaper Ad Name of Newspaper: 2. Internet via: Banner Ad Search via pdskin.com Search using Google, Yahoo, or Bing Search via our physician s name Other: 3. Our Website via: Directly typing Premier Dermatology Directly typing a PD physician s name 4. Outdoor: Message Board (Crest Hill site only) Directly typing pdskin.com Other: Billboard 5. Train Platform: METRA CTA Elevated 6. Drive by the office 7. Radio 8. Magazine 9. Yellow pages (Phone book) 10. I was referred by a Premier Dermatology physician name: 11. I was referred by an esthetician from the spa name: 12. I was referred by a physician from another office Name of Physician: 13. I was referred by a friend or family member Name : 14. I was referred by a staff member of Premier Dermatology Name: 15. Insurance preferred provider list 16. I am already a patient 17. Direct Mail 18. Health Fair/Skin Screening/Lunch n Learn/Education Seminar (circle one); Location: 19. Zoc Doc Location: CH N M Y NL OP Staff initials

2 Name DOB MEDICAL HISTORY Dermatologic History: None Melanoma No Yes Explain: Basal Cell Carcinoma No Yes Explain: Squamous Cell Carcinoma No Yes Explain: Psoriasis No Yes Eczema No Yes Hay Fever No Yes Asthma No Yes Medical History: None Surgical History: None Family History: None Melanoma No Yes Explain: Basal Cell Carcinoma No Yes Explain: Squamous Cell Carcinoma No Yes Explain: Psoriasis No Yes Eczema No Yes Hay Fever No Yes Asthma No Yes Allergies: Social History: Occupation: Alcohol: Yes No Amount: Tobacco: Yes No Amount: Drug Use: Yes No Explain: Sun Exposure: Heavy Moderate Minimal History of Blistering: Sunburn Yes No Tanning Bed Use: No Yes, Current Yes, Past Sunscreen: Always Occas. Never Other Pertinent Family History: None Medication Data Dose Start Stop

3 New Patient Information Patient Name DOB Last First Middle MM/DD/YY Address Street Apt/Unit No. City State Zip Phones H C W Ext# Preferred Contact # Home Cell Work I authorize contact by cell Y N Employer Gender Male Female Marital Status S M W D Student Y N SS # Sign me up for Portal ( Required) Y N Already Signed Up Pharmacy Cross Street(s) City Referring Physician Phone Fax Primary Care Physician _ Phone Fax Race Declined Ethnic Group Declined Language Arabic Chinese English American Indian or Alaska Native Hispanic or Latino French German Japanese Asian Not Hispanic or Latino Russian Spanish Vietnamese Black or African American Native Hawaiian or Other Pacific Islander White Other REQUIRED PRIMARY INSURANCE INFORMATION Primary Insurance Company Policy Holder s Name DOB Relationship SECONDARY INSURANCE INFORMATION Secondary Insurance Company Policy Holder s Name DOB Relationship MUST COMPLETE IF PATIENT IS A MINOR Father s Name Address Phone # SS # DOB Employer Mother s Name Address Phone # SS # DOB Employer Revised

4 Patient Agreement I hereby authorize the release of pertinent medical information to my insurance carriers. I am aware health insurance coverage varies and, insurance carriers may use terms such as customary, reasonable, prevailing, etc. to limit their coverage. I am ultimately responsible for payment of all charges for services rendered by the physicians of Premier Dermatology. As well as other charges for laboratory fees, pathology fees, and any other fees incurred as a result of the treatment rendered to myself or my immediate family. If I have insurance which the doctors are contracted with, I understand that I will be responsible for any co- payments, deductibles, co- insurances, or a procedure that is not considered medically necessary by my insurance carrier. I understand and agree that if I fail to keep my scheduled appointment and I do not give at least 24 hours notice of cancellation I will be charged a no- show fee. The no- show fee is $50 for a regular medical visit and 50% of the anticipated cost of scheduled surgical procedures. A Saturday no- show fee is $100. Cosmetic services require a 48- hour notice of cancellation. The no- show fee is $99 for a cosmetic consultation. No- show charges are not billable to your insurance. In the event I fail to pay the balance of my account to Premier Dermatology, I hereby agree that, in the event Premier Dermatology sends my account to a collection agency, I will pay the fee charged by the collection agency to Premier Dermatology. In addition, if my account is forwarded to an attorney to undertake legal action to collect the unpaid balances, I hereby agree to pay all of the reasonable attorney fees incurred by Premier Dermatology, in regards to the collection of this unpaid account. I have also been given a copy of the Office Policy and understand that the Office Policy is incorporated by reference and made a part hereof this agreement. Print Patient Name Signature of Patient/Responsible Party

5 NOTICE OF PRIVACY ACKNOWLEDGMENT OF RECEIPT By signing this form, you acknowledge receipt of the Notice of Privacy Practices of Premier Dermatology. Our Notice of Privacy Practices provides information about how we may use and disclose your protected health information (as that term is defined under the Health Insurance Portability and Accountability Act of 1996 HIPAA ). We encourage you to read it in full. Print Patient Signature of Patient/Responsible Party

6 DISCLOSURE OF INFORMATION I give Premier Dermatology full permission to contact me and/or the individuals that I have designated below for the purpose of disclosing detailed information pertinent to my care. This would include, but not be limited to, information regarding pathology reports, laboratory tests, scheduling, and business information. By my signature below, I agree to hold harmless and waive any liability against Premier Dermatology for the disclosure of information to me and/or the individual(s) designated below. I authorize Premier Dermatology to contact for results: 5 Myself Only 5 Home: ( 5 Cell: ( 5 Work: ( ) - ) - ) - 5 Other: 5 Other: Name: Name: Relationship: Relationship: Phone #: ( ) - Phone #: ( ) - Voic 5 Yes, please leave a message with results and detailed medical information. 5 No, do not leave a message with results and detailed medical information. Print Patient Name Signature of Patient/Responsible Party

7 CONSENT TO OBTAIN MEDICATION HISTORY As a user of an electronic medical record, we would like to include your medication history in your record. A medication history is a list of prescription medicines that we or other doctors have prescribed for you. This list is collected from several sources, including your pharmacy and your health insurance carrier. An accurate medication history is very important to help us treat you and to avoid potentially dangerous drug interactions. By signing this consent form you give us permission to collect and give your pharmacy and your health insurance carrier permission to give us information about your prescriptions that have been filled at any pharmacy or covered by any health insurance plan. This includes prescription medicines to treat AIDS/HIV and medicines used to treat mental health conditions, such as depression. This information will become part of your electronic medical record, should your provider feel it is important to your medical care. This medication history is a useful guide, but it may not be complete. Some pharmacies do not make drug history available to us, and the drug history might not include drugs that you purchased without using your health insurance. Your medication history might not include over the counter medicines, supplements or herbal remedies. It is still very important for us to take the time to discuss everything you are taking, and for you to tell us about any errors in your medication history. Please select /check only one: I give permission for Premier Dermatology to obtain my medication history from my pharmacy, health insurance carrier, or other healthcare providers. I give restricted consent for Premier Dermatology to obtain only prescriptions written by the current provider. I DO NOT give permission for Premier Dermatology to obtain my medication history from my pharmacy, health insurance carrier, nor other healthcare providers. Print Patient Name Signature of Patient/ Responsible Party

8 PERMISSION TO PHOTOGRAPH I, (name of patient), hereby authorize the taking of my photograph(s) by Premier Dermatology and its designated employees. I fully understand such photograph(s) may be necessary for documentation related to my medical, surgical or cosmetic care. Signature of Patient/Responsible Party Witness

9 Premier Dermatology invites you to join our patient portal. Access your health information Anytime. Anywhere. Request Medication Refills (Health Summary tab) View Clinical Summary (Visit/Results tab) View Health Summary View and Confirm Upcoming Appointments Request Updates to Your Information What is a Patient Portal? A patient portal is a secure online website that gives you convenient 24- hour access to your personal health information and medical records called an Electronic Health Record or EHR from anywhere with an Internet connection. Why is a Patient Portal Important? Accessing your personal medical records through a patient portal can help you be more actively involved in your own health care. Accessing your family members health information can help you take care of them more easily. Also, patient portals offer self- service options that can eliminate phone tag with your doctor. Provide us with your preferred address so we can give you access to the Pa=ent Portal A Portal Registra=on is automa=cally sent to you containing a registra=on link Click on the registra=on link What if I don t receive a registration ? Be patient. The s may take a few minutes to deliver. You may also check your junk mail or spam folders to see if the was routed there by mistake. If necessary, you can call the office to re- send the registration . Also, failure to register your portal account within three days will inactivate your registration. If this happens, please contact the office to send you a new registration. Is my Information Safe? Yes. Patient portals have privacy and security safeguards in place to protect your health information. Always remember to protect your user name and password from others and make sure to only log on to the patient portal from a personal or secure computer. Enter the requested personal informa=on to verify your iden=ty Follow the instruc=ons for crea=ng a user name and password Confirm your personal and insurance informa=on on the next screen EXPLORE!

10 Credit Card Authorization For Internal Use Only Patient Acct# CH M N Y NL OP Staff Initials: I,, authorize Premier Dermatology to keep my signature on file and to charge my credit card listed below for: _ All patient balances (Less than $250.00) for services rendered once the claim has been processed by my insurance company. I understand that Premier Dermatology will contact me by telephone for all patient balances exceeding $ prior to charging my card. _ Recurring charges for services rendered for the following family members: Patient Name: Patient Name: Patient Name: Patient Name: DOB: DOB: DOB: DOB: Check one: Visa Mastercard Discover American Express* * I am waiving the 10 day prior notification for any transaction processed on my American Express card. * AMEX Cardholder Signature * Cardholder Name _ Billing Address City State Zip Credit Card Number Expiration _ CVV# (last three numbers on the back, four numbers on the front of American Express) Cardholder Signature Cardholder/Patient Preferred Contact Phone Number I have the right to terminate this authorization at any time and agree to do so by contacting Premier Dermatology s business office at (815) option #2.

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