PatientPop



WELCOME TO HEIGHTS DERMATOLOGY AND LASER

PLEASE TELL US ABOUT YOURSELF:

Last Name: First Name: M.I.: _____________

Address:__________________________________ _ Apt. #:_____________

City:_______________________ State:_____________ Zip:____________

Home Phone: Business Phone:

Cell Phone: Email:

Social Security #: Gender: M or F

Date of Birth: ___________________ Marital Status: ___________________

Please check where we can leave a message if necessary: Home Business Cell

Emergency Contact Name & Phone Number:

Name of guardian, if patient is a minor: _______________________________

Primary Care Physician Address and Telephone #:

____________________________________________________________

Preferred pharmacy Name: _____________________________ Phone#: _______________________________

Insurance Name: _________________________________ Insurance ID: _______________________________

For MEDICARE patients:

I hereby authorize payment of medical benefits to Heights Dermatology and Laser Group MD PC

Signature:_____________________________________________ Date:___________________________

All patients:

I hereby give permission to bill my insurance company. I realize I am financially responsible for any unpaid balance, deductible or coins. I understand my insurance company will not pay for cosmetic procedures, therefore I am responsible for payment in full.

Signature:_____________________________________________ Date:___________________________

*****Please tell us your reason for being seen today *****

Would you also like information on:

Skin Cancer

Psoriasis, Eczema, Acne, skin care

Hair Transplantation

PRP

Laser for fat removal

Laser for wrinkles

Laser for hair removal

Laser for redness

Fillers and Botox

Medications: (Please enter all current medications)

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________

Allergies: (Please enter all allergies)

__________________________________________________________________________________________________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________

Referring physician name and phone number, if different from PCP

__________________________________________________________

History and Intake Form

Past Medical History: (please circle all that apply)

Anxiety

Arthritis

Asthma

Atrial fibrillation

Bone Marrow

Bleeding disorder

Transplantation

Breast Cancer

Colon Cancer

COPD

Coronary Artery Disease

Depression

Diabetes

End Stage Renal Disease

GERD

Hearing Loss

Hepatitis

High Blood pressure

HIV/AIDS

High Cholesterol

Thyroid Problems

Leukemia

Lung Cancer

Lymphoma

Prostate Cancer

Radiation Treatment

Seizures

Stroke

Do you need prophylaxis?:_______

NONE

Other _________________________________________________________________________________________

Past Surgical History: (please circle all that apply)

Appendix Removed

Bladder Removed

Mastectomy (Right, Left, Bilateral)

Lumpectomy (Right, Left, Bilateral)

Breast Biopsy (Right, Left, Bilateral)

Breast Reduction

Breast Implants

Colectomy: Colon Cancer Resection

Colectomy: Diverticulitis

Colectomy: IBD

Gallbladder Removed

Coronary Artery Bypass

Mechanical Valve Replacement

Biological Valve Replacement

Heart Transplant

Joint Replacement, Knee (Right, Left, Bilateral)

Joint Replacement, Hip (Right, Left, Bilateral)

Joint Replacement within last 2 years

Kidney Biopsy (Nephrectomy)

Kidney Removed (Right, Left)

Kidney Stone Removal

Kidney Transplant

Ovaries Removed: Endometriosis

Ovaries Removed: Cyst

Ovaries Removed: Ovarian Cancer

Prostate Removed: Prostate Cancer

Prostate Biopsy

TURP (Prostate Removal)

Spleen Removed

Testicles Removed (Right, Left, Bilateral)

Hysterectomy: Fibroids

Hysterectomy: Uterine Cancer

None

Other________________________________________

Skin Disease History: (please circle all that apply)

Acne

Actinic Keratoses

Asthma

Basal Cell Skin Cancer

Blistering Sunburns

Dry Skin

Eczema

Flaking or Itchy Scalp

Hay Fever/Allergies

Melanoma

Poison Ivy

Precancerous Moles

Psoriasis

Squamous Cell Skin Cancer

NONE

Other ________________________________________________________________________________________

Is it possible you are pregnant?__________________

Are you breast feeding? __________________

Do you wear Sunscreen? Yes No

If yes, what SPF? ___________

Do you tan in a tanning salon? Yes No

Do you have a family history of Melanoma? Yes No

If yes, which relative(s)? ___________________________________________________________________

Social History: (Please circle all that apply)

Cigarette Smoking:

Current smoker

Smoked in the past

Never smoked

Former Smoker

Alcohol Use:

None

Less than 1drink per day

1-2 drinks per day

3 or more drinks per day

Family History (Only first degree relatives)

__________________________________________________________________________________________________________________________________________________________________________________________________________________

Preferred Language: _____________________________ Race:______________________

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