Patient Legal Name



Patient Legal Name Last First Middle Initial Today’s Date

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Mailing Address Street City and State Zip Home Telephone

Age Birth Date Gender Marital Status Cell Phone

M F S M W D

Race Social Security No Email Address

Employer’s Name and Address Street City and State Zip Business Telephone

Patient’s Occupation Emergency Contact other than Spouse Emergency Telephone

SPOUSE OR RESPONSIBLE PARTY INFORMATION

Responsible Party/Spouse Name Birth Date Social Security No Relationship to Patient

Street Address City and State Zip Code Home Telephone

Responsible Party/Spouse Occupation Responsible Party/Spouse Employer

INSURANCE INFORMATION

PRIMARY INSURANCE COMPANY

Name Policy Holder Name Date of Birth Employer

SECONDARY INSURANCE COMPANY

Name Policy Holder Name Date of Birth Employer

REFERRAL INFORMATION

REFERRAL BY A DOCTOR REFERRAL BY A FRIEND OR FAMILY MEMBER

Physician Name Physician Phone Name Relationship

MEDICAL QUESTIONS

Are you ALLERGIC to any MEDICATION? Do you have now, or have you ever had diseases or conditions listed below:

If YES, please list them: NO YES Lungs YES NO Other Systemic: YES NO

__________________________________________ Bronchitis   Glaucoma  

__________________________________________ Asthma   Diabetes  

__________________________________________ Emphysema   Thyroid  

_______________________________________________ Kidney  

ALLERGY TO LATEX? NO YES Bladder  

List All Medications currently taking: Vascular Stomach  

__________________________________________ High Blood Pressure   Bowel  

__________________________________________ Chest Pain   Genital Problems  

__________________________________________ Heart Attack   Arthritis, Joint deformity  

__________________________________________ Irregular Heart Beat   Artificial Joints  

__________________________________________ Phlebitis   Convulsions, Epilepsy, __________________________________________ Defibrillator   or seizures  

Pharmacy Name and Address: Pacemaker   Fainting  

__________________________________________ Bleeding Problems   Neurological/Psychiatric  

__________________________________________ Do You Smoke?   SKIN CANCER  

List Previous Hospitalizations: Other Skin Diseases____________

________________________________________ If Female, are you Pregnant? YES NO ____________________________

________________________________________ Due Date?______________________ ____________________________

List Previous Surgeries: If Female: Last Menses _________________

_______________________________________

_______________________________________ Other Medical Problems not listed:__________________________________

List Medical Problems that run in your family: ______________________________________________________________

_______________________________________ HAVE YOU HAD ANY OF THE FOLLOWING SERIOUS CONDITIONS?

_______________________________________ Hepatitis A B C YES NO HIV YES NO

Please List your Personal PHYSICIAN/Address: Tuberculosis YES NO MRSA YES NO

_______________________________________

_______________________________________ AUTHORIZATION TO TREAT

I (or the undersigned on behalf of the patient) authorize the attending physician(s) or his/her designee under supervision, to provide medical treatment. I understand I am financially responsible for and agree to pay charges not paid by my insurance company. Date:_______________

Patient/Legal Guardian Signature:__________________________________________Print Name:_________________________________

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