Intake form

Patient Information

Please complete this form before your visit. This form is for all patients (new and existing, virtual and in-person visits).
I am a... *

New Patient Existing Patient (who has seen Dr. Khalil within the last 3 years) Existing Patient (who has not seen Dr. Khalil in 3+ years)
Is this for an in-person or virtual visit? *

In-Person Visit Virtual Visit
Would you like your virtual visit to be a phone call or a video call? *

Phone call Video call
**Please note: To begin your telehealth visit, please follow this link: https://doxy.me/drdavidkhalil. Dr. Khalil will log into the video call at the approximate scheduled time of your visit. Due to in-office procedures, there may be a wait-time for your virtual visit. We greatly appreciate your flexibility and patience.
**Please note: Dr. Khalil will telephone you directly at the approximate time of your visit. Due to in-office procedures, there may be a wait-time for your virtual visit. We greatly appreciate your flexibility and patience.
Name *

First Name Last Name
Preferred Name (if different from above)
Please leave blank if not different from above.
Birth Date *

Month Day Year
Social Security Number (SSN)
If you do not have a Social Security Number, please write "none." If you prefer, you may also disclose this to us in-office.
Has your mailing address changed since your last visit? *

Yes No Unsure
Address *

Street Address

Apartment Number (if applicable)

City State / Province

Postal / Zip Code
Email Address *
Phone Number *
Sex (assigned at birth) *
Females *

Trying to conceive Pregnant Breastfeeding None of the above
Gender Identity (if different from above)
Please leave blank if not different from above.
Marital Status *
Occupation *
Please upload a photo of your driver's license or other government issued photo ID card. If you prefer, you can also physically provide this in-office at the time of visit.
Primary Care Physician (PCP) *
If you do not have a PCP, please write "none."
Referring Physician *
If you do not have a referring physician, please write "none."
Emergency Contact Information

(Optional)
Name

First Name Last Name
Phone Number

Area Code Phone Number
Relationship to Patient

Spouse/Partner Parent/Guardian Sibling Other Family Member Friend Other
Medical Information
Reason for Visit *
Please be as detailed as possible. Include duration, treatments tried, triggering factors, getting better or worse with time, etc.
Photos are recommended for virtual visits. If you are not able to send photos using the below, please email the images to info@dkdermatology.com.
Photo #1 of the skin condition

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Photo #2

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Photo #3

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Photo #4

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Photo #5

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Current Medications *
Please include over-the-counter, prescription, vitamins, and herbal remedies. If no medications, please write "none".
Allergies *
Please include medications and environmental allergies (e.g. hay fever, dust mite, pollen). If no allergies, please write "none".
Recently had (past 14 days)? *

fever chills cough nausea vomiting diarrhea weight changes night sweats joint pain vision changes loss of smell or taste shortness of breath, difficulty breathing, or requiring more energy than usual to breathe close contact with a person with the above symptoms in the past 14 days none of the above
Recent travel (past 3 months)? *

Yes No
Please specify where and when. *
Please include state/province and country name.
Do you have a history of any skin conditions? (choose all that apply) *

abnormal moles acne atypical (dysplastic) moles basal cell carcinoma (skin cancer) bleed easily boils changes in moles cold sores (HSV1) dry skin eczema herpes (HSV2) hives HPV itching melanoma (skin cancer) other skin cancer pre-skin cancer (actinic keratosis) psoriasis rosacea sensitive skin squamous cell carcinoma (skin cancer) scars sores that do not heal warts other (please specify below) none of the above
Any updates to personal or family medical or psychiatric history since your last visit? *

Yes No
Do you have a history of any medical or psychiatric conditions? (choose all that apply) *

alcoholism anemia anxiety arthritis asthma AIDS/HIV bleeding disorder blood disease blood transfusion cancer Crohn's disease diabetes depression eating disorder epilepsy hay fever heart disease heart problems hepatitis A hepatitis B hepatitis C high blood pressure (hypertension) high cholesterol irritable bowel syndrome (IBS) joint disorder kidney disorder liver disorder lung disease lupus measles migraines osteoporosis pacemaker rheumatic fever sinus problems stroke stomach ulcer substance abuse thyroid disorder tuberculosis ulcerative colitis venereal diseases none of the above
Personal Medical and Psychiatric History *
Please include any medical conditions, hospitalizations, and surgeries. If no personal history, please write "none".
Family Medical and Psychiatric History *
Please include any medical conditions. If no family history, please write "none".
Do you have any family history of skin cancers (basal cell carcinoma, squamous cell carcinoma, melanoma)? *

Yes No
Have you ever been hospitalized? If yes, please specify when and why. *
Please type "no" if you have never been hospitalized before.
Have you had any surgeries? If yes, please specify what and when. *
Please type "no" if you have never had any surgeries before.
Do you smoke or use recreational drugs? If yes, please specify type and frequency of use (recreational drugs can cause some skin conditions). *
Please type "no" if you do not smoke or use recreational drugs of any kind.
We recommend full body skin exams to check for skin cancer at least once per year for all adults. Please schedule with the front desk if you are interested.
When was your last full body skin exam? *
If you have never had a full body skin exam, please write "never."
We specialize in medical and cosmetic treatments. Are you interested in the following cosmetic treatments? Please note that cosmetic treatments are not covered by insurance. *

acne scar treatment BOTOX to prevent or treat fine lines and wrinkles BOTOX to underarms (to combat sweating) brown spot removal cheekbone enhancement chemical peel for facial "glow" and skin rejuvenation chin augmentation cosmetic mole removal facial slimming (BOTOX to masseter) gummy smile correction (with BOTOX) lip enhancement milia (white spot) removal skin dermal fillers skin tag removal tear trough (under eye) filler torn ear lobe repair none of the above
Questions? Call (646.793.4226) or email us (info@dkdermatology.com).
Medical Insurance Information
Accepted Medical Insurances: Aetna, Blue Cross Blue Shield (except with member ID prefix JLJ), Bright Health, Centivo, Cigna, EmblemHealth HIP (except Enhanced Care or Essential policies, not GHI), First Health (not HealthFirst), HealthPartners, Humana, Medicare, Meritain Health, Nippon Life Insurance, Oscar, and UnitedHealthcare (Liberty and Freedom policies only).

We accept 1199, Emblem Health GHI, Fidelis (Essential Plan and metal-tier plans only, no Medicaid), UnitedHealthcare Choice Plus, UnitedHealthcare The Empire Plan, and UnitedHealthcare Metro for existing patients only. We do not accept these policies for new patients. We greatly apologize for any inconvenience.

Sorry, but we do not accept any Medicaid or Worker's Compensation policies.

Please Note: If you have two insurances, please make sure to list both in the correct order (or the insurance company will deny the claim).
Has your insurance changed since your last visit? *

Yes No Unsure
Primary Insurance *

Aetna Blue Cross Blue Shield (except member ID prefix JLJ) Bright Health Centivo Cigna EmblemHealth HIP (except Enhanced Care or Essential policies, not GHI) First Health (not HealthFirst) HealthPartners Humana Medicare Meritain Health Nippon Life Insurance Oscar UnitedHealthcare Liberty or Freedom Self-Pay Other (please note that if we do not accept your insurance, you will be Self-Pay)
If you are not the insurance policy holder, please specify the name and date of birth of the policy holder, as well as your relationship to them. *
If you are the policy holder, please write "N/A".
Clear photos of both sides of the insurance card are required. If you are not able to submit photos using the above, please email them to info@dkdermatology.com.
Primary Insurance Card (front)

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Primary Insurance Card (back)

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Does your insurance require a referral to see a specialist? (If you are unsure, please contact your insurance company directly before your visit. Note that most HMO plans and most Student Health plans require referrals.) *

Yes No
Do you have a referral from your assigned PCP that was already sent to the office (by email, fax, and or post)? *

Yes No
I understand that I am being asked to sign this form because I have not provided a referral before my appointment with Dr. Khalil, a specialist doctor (dermatologist). There is no guarantee that a referral received after the date of my visit or a referral from a doctor that is not my assigned physician on file with my insurance company will be accepted. Most often these referrals are rejected. If I cannot produce a referral valid for the date of my visit that my insurance accepts, I acknowledge that the balance from my visit claim will defer unto me in full. It is my sole responsibility to pay off this balance in a timely manner, or I will face collections charges. I have read, understand, and agree with this.

Yes
Signature *

Clear
Do you have a secondary insurance policy? *

Yes No
Secondary Insurance *
Secondary Insurance Card (front)

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Secondary Insurance Card (back)

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If you are not the insurance policy holder, please specify the name and date of birth of the policy holder, as well as your relationship to them. *
If you are the policy holder, please write "N/A".
Insurance Terms

Copay - The fixed amount you pay for a health care service (e.g. $50 copay per visit).

Deductible - The amount you pay for health care before your insurance benefits take effect. If you have a $500 deductible, you pay $500 before your insurance will begin to pay. If you have an unmet deductible you will receive a bill after your visit, even if we are considered a "covered, in-network physician". This is because with a deductible, the patient first has to pay for their medical expenses. An office visit is usually several hundred dollars, and the exact price is determined by the insurance company.

Coinsurance - The percentage of health care costs you pay once your insurer covers its share (e.g. if you have 20% coinsurance, you pay $2.00 of every $10.00 in health care costs).

Specialist Visit - All dermatology visits are considered "Specialist Visits" by insurance companies. Specialist fees apply, including but not limited to specialty copays, coinsurances, and deductibles. Please note that dermatology visits are not considered preventative by insurance companies, including for annual skin exams/skin cancer screenings.

**Please contact your insurance company if you have any questions about your individual policy's applicable coverage and costs before your visit.**
Are you familiar with and understand the terms copay, coinsurance, and deductible? *

Yes No
**Please contact your insurance company if you have any questions about your individual policy's applicable coverage and costs before your visit.**
I understand that all visits and procedures are subject to specialty copays, coinsurances, and deductibles. This includes, but is not limited to: annual skin exams/skin cancer screenings (note that these are NOT considered "preventative" exams by insurance companies), follow-up visits, discussion of biopsy results, suture removal, skin biopsies, wart freezing, injection of intralesional skin steroids, skin paring, skin cyst drainage. *

Yes No
**Please contact your insurance company if you have any questions about your individual policy's applicable coverage and costs before your visit.**
I understand that all skin biopsies and skin swabs are sent to a lab for analysis. I understand that I may receive a billing statement from the lab if I have a lab copay, coinsurance, and or deductible. Please note that we are not directly affiliated with any labs, and we encourage you to reach out to them directly if you have any questions regarding this. *

Yes No
**Please contact your insurance company if you have any questions about your individual policy's applicable coverage and costs before your visit.**
I understand that it is my responsibility, and not the responsibility of the office, to know the details of my insurance coverage, benefits, and costs. *

Yes No
**Please contact your insurance company if you have any questions about your individual policy's applicable coverage and costs before your visit.**
Pharmacy Information
All medications are sent electronically to your pharmacy after your visit. Most medications that we prescribe are generic and have been around for decades. However, insurance companies sometimes do not cover even generic medications. To help with this, we recommend using a specialty pharmacy called Third Ave Apothecary (located on 61st and 3rd) that automatically applies medication coupons and has free delivery in New York and New Jersey. If you choose to use your own pharmacy, please remind the pharmacist to use manufacturer medication coupons (often found simply by searching Google or other search engines for the medication name and the words "coupon card"). Please let us know if you have any questions.

Yes, please send my scripts to Third Avenue Apothecary Pharmacy. No, please send my scripts to my pharmacy on file. No, please send my scripts to my pharmacy listed below.
All medications are sent electronically to your pharmacy after your visit. Most medications that we prescribe are generic and have been around for decades. However, insurance companies sometimes do not cover even generic medications. To help with this, we recommend using a specialty pharmacy called Third Ave Apothecary (located on 61st and 3rd) that automatically applies medication coupons and has free delivery in New York and New Jersey. If you choose to use your own pharmacy, please remind the pharmacist to use manufacturer medication coupons (often found simply by searching Google or other search engines for the medication name and the words "coupon card"). Please let us know if you have any questions.

Yes, please send my scripts to Third Avenue Apothecary Pharmacy. No, please send my scripts to my pharmacy listed below.
Pharmacy Name *
Scripts are sent electronically to this pharmacy.
Pharmacy Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Consent
I have completed this form accurately and completely. I am responsible for information that is omitted and hold the provider harmless for medical decisions made without this information.

I understand that it is my responsibility, and not the responsibility of the office, to know the benefits and limitations of my insurance. I understand that I am responsible for charges not paid by my insurance company. These include but are not limited to co-pays, deductibles, co-insurances, procedures, lab tests, and referrals. I understand that it is my responsibility to know whether or not my insurance covers non-emergency care in New York state. If a referral is required, it is my responsibility to know this and have a referral on the correct insurance form prior to my visit or I will be responsible for the visit cost. I understand that it is my responsibility to know if the physician and lab is a contracted in-network facility recognized by my insurance plan, or I may be responsible for out-of-network amounts. I understand that the provider does not accept Worker's Compensation-related insurance packages or policies.

I agree that DK Dermatology PLLC may use my health information for diagnosis, treatment, payment, insurance billing, credit card payments and chargebacks, and health care operations. I consent to access and share my medical information with my insurance company, health care providers, pharmacies, and hospitals. I acknowledge receipt of the Notice of Privacy Practices. The Notice of Privacy Practices may change at any time, and I can obtain a copy at the front desk or via email. I agree that by including my phone number and or email address, I am consenting to be contacted via phone, text, voicemail, and email with my medical information.

I understand that virtual visits are processed by insurance companies like in-person visits, and I may be responsible for copay, deductible, and co-insurance. I understand that many but not all skin conditions can be diagnosed and treated through a virtual visit. A virtual visit is not as accurate as an in-person visit. The virtual visit is not refundable.

Definitions

Copay - The fixed amount you pay for a health care service (e.g. $50 copay per visit).

Deductible - The amount you pay for health care before your insurance benefits take effect. If you have a $500 deductible, you pay $500 before your insurance will begin to pay.

Coinsurance - The percentage of health care costs you pay once your insurer covers its share (e.g. if you have 20% coinsurance, you pay $2.00 of every $10.00 in health care costs).

Please contact your insurance company if you have any questions about your individual policy and healthcare benefits or costs before your visit.

I understand that if a biopsy/excision site requires sutures (stitches), I must return in 7 days for suture removal, wound check, and a discussion of the pathology results. I acknowledge that this follow-up visit is subject to copays, coinsurances, and deductibles and that these charges are not included in the initial encounter office visit.

I understand that it is the patient's (my) responsibility to schedule follow-up visits, especially if the my condition is not improving, not responding to treatment, worsening, bleeding, hurting, enlarging, and or changing. I will not hold the office liable if my condition worsens due to my lack of follow-up.

To protect against the transmission of blood-borne diseases if an accidental blood or bodily fluid exposure occurs, I understand and agree that it may be necessary to test my blood for certain diseases (e.g. hepatitis and human immunodeficiency virus).

We recommend yearly (at least) skin exams for all adults to check for skin cancer by a dermatologist. We also recommend monthly self-skin checks for all adults. I understand it is my responsibility to schedule skin exams if I am interested. I also understand that most insurance companies do not consider annual skin exams by a dermatologist to be "preventative" and may not offer "preventative" coverage for said exams.

If I am paying by credit card, I agree that my credit card will be kept on file and used for healthcare payments (e.g. copay, deductible, co-insurance) by Elavon secure credit card processing system. I agree that if I cancel my appointment without providing 24 hours of advance notice that I will be responsible for a $50 fee.

I understand that if I have an outstanding balance with the practice (whether due to Self-Pay charges, insurance deductible charges, coinsurance charges, copay charges, or any other such charge) it is my responsibility to pay this balance off in a timely manner. If my bill is not paid in full within 90 days of my visit, I understand that my account may be adjudicated by a collections agency, for which I am therefore responsible for any collections fees, legal fees, or other such fees.

By signing below, I certify that I understand and agree to this consent form.
Coronavirus (COVID-19) Consent
The office takes several precautions to prevent the transmission of coronavirus, including cleaning the office multiple times per day, wearing gloves and masks, and screening guests and staff for symptoms of coronavirus. However, it is not possible to guarantee a zero percent risk of exposure. By coming to the office, I understand that there may be a risk of exposure to coronavirus, and I do not hold the office responsible for this.

Signs, Symptoms, and Risk Factors of Coronavirus
- fever
- chills
- cough
- fatigue
- body or muscle aches
- headache
- sore throat
- congestion or runny nose
- nausea, vomiting, or diarrhea
- loss of taste or smell (one of the earliest symptoms)
- shortness of breath, difficulty breathing, or requiring more energy than usual to breathe
- being in close proximity to a person with the above symptoms

By coming to the office, I agree that I have not had any sign, symptom, or risk factor (see above) for coronavirus for at least 14 days before my visit.

Please wear a mask on the day of your visit (required by our building in order to enter). Please keep your mask on inside the office for the entire duration of your visit.

Please do not bring guests or family members with you. We can instead include them by phone or video if applicable.

When you do come to the office, we will check your temperature, check your sense of smell, and provide you with gloves. If you have any sign of coronavirus, we will re-schedule your appointment.

By signing below, I certify that I understand and agree to this consent form.
Signature *

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Coronavirus (COVID-19) Consent