Patient Registration & Health Questionnaire

Last Name

M. I.

First Name

Date of Birth +

Age

Sex

M

F

Social Security #

Address

City

State

Zip Code

Home Phone #

Mobile #

Work Phone #

Preferred Number

Home

Mobile

Work

May we leave a detailed message?

Yes

No

May we text appointment reminders?

Yes

No

Email

May we email appointment reminders?

Yes

No

Would you like to be notified of promotions and events?

Yes

No

Emergency Contact Name

Emergency Contact Phone #

CONSENT TO DISCUSS CARE. If you are 18 years or older we cannot discuss your care with other family members, spouses or caretakers without your consent. Do you authorize consent for any other individuals?

Yes

No

If yes:

Name

Relationship

Phone #

Employer

Occupation

Primary Care Physician (Name and Location)

How did you hear about us?

Preferred pharmacy (Name and Location)

Past Medical History

Past Surgical History (including dates)

Skin Disease History

History of Skin Cancer

	Location	Year
Basal Cell:	Location	Year
Melanoma:	Location	Year
Squamous cell:	Location	Year
Unknown:	Location	Year
Other:	Location	Year

Do you wear Sunscreen?

Yes

No

If yes, what SPF? 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, who? If yes, who?

Medications (Prescription, over-the-counter, and herbal)

Allergies

Cigarette Smoking

Never smoked

Quit: former smoker

Current every day smoker

Current some day smoker

Do you have any of the following?

Alerts

Would you like information on any of the following:

INSURANCE INFORMATION

ELIGIBILITY: Please be aware that your health insurance policy is a contract between you and your insurance company. It is an agreement that your insurance will pay for covered medical services as long as your premiums are paid. Because they may not pay for every service, you will be responsible for any non-covered charges. We will verify your eligibility before your visit but please keep in mind that a determination of benefits with your carrier is NOT a guarantee of payment.

DEDUCTIBLES: Before your visit, we will verify your deductible and/or co-pay amounts. If your annual deductible for
the calendar year has not been met, you will be responsible for any charges incurred during your visit, payable at the
time of service. We will also collect any co-pay amounts at the time of service.

OUTSIDE SERVICES: Please be aware that your care may require the use of laboratory or pathology evaluation. These studies are not performed at our practice so please understand that you will receive a separate bill from the pathologist or laboratory providing those services. If you have a preference for a specific facility, please notify us prior to any procedure so that we can do our best to accommodate you.

I authorize my insurance benefits to be paid directly to the physician. I understand that I am financially responsible for the services provided. I also authorize El Segundo Dermatology or my insurance company to release any information required to process my claim.

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Date: +

ACKNOWLEDGEMENT OF PRIVACY PRACTICES

I hereby acknowledge that I have received a copy of El Segundo Dermatology's Notice of Privacy Practices.

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CONSENT FOR TREATMENT

I understand that many dermatological conditions are chronic and require ongoing care. All medications have side effects and there are risks to any medication prescribed. Dermatologists frequently diagnose skin growths by
performing a skin biopsy and treat skin growths by freezing, cauterization, and/or cortisone injection.
I understand that there are risks to any procedure and that these risks include, but are not limited to:

-Temporary or permanent discoloration

-Scarring
-Pain

-Infection
-Bleeding

-Nerve damage

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All information entered into this form is transmitted through a secure network directly to our office and becomes protected health information.