Intake form

Patient Information

Please complete this form before your visit. This form is for all patients (new and existing, telehealth/virtual and in-person visits). If you are under 18, please have your parent/guardian complete and sign this form.
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 telehealth/virtual visit? *

In-Person Visit Telehealth/Virtual Video Visit
Would you like your telehealth/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.
Patient Legal Name *

First Name(s) and Middle Initial(s) if applicable Last Name(s)
Preferred Name (optional/if different from legal name 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 (U.S. addresses only) *

Street Address

Apartment Number (if applicable)

City State / Province

Postal / Zip Code
Patient/Guardian Email Address *
Patient/Guardian Phone Number (U.S. phone numbers only) *

Area Code Phone Number
Patient Sex (assigned at birth) *

Male Female
Are you... *

Trying to conceive Pregnant Breastfeeding None of the above
Gender Identity (optional)
Please leave blank if not different from above.
Marital Status *
Occupation *
If you do not have an occupation, please type "none".
Please upload a photo of your driver's license or other government-issued photo ID. (optional)

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If you prefer, you may provide your photo ID in-person at the time of your visit. Cancel of
Primary Care Physician/PCP (optional)
If you do not have a PCP, please leave blank.
Referring Physician (optional)
If you do not have a referring physician, please leave blank.
Emergency Contact (optional)
Emergency Contact Name

First Name(s) Last Name(s)
Emergency Contact Phone Number

Area Code Phone Number
Relationship to Patient (choose the option that best matches your relationship with this person)

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

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Current Medications *
Please include all over-the-counter products, prescription medications, vitamins, herbal remedies, etc. If no medications, please write "none".
Allergies *
Please include medications and environmental allergies (e.g. hay fever, dust mites, pollen). If no known allergies, please write "none".
Have you experienced any of the below in the past 14 days? *

fever chills cough nausea vomiting diarrhea weight gain intentional weight loss unintentional weight loss night sweats joint/muscle pain vision changes loss of smell or taste shortness of breath, difficulty breathing, or requiring more energy than usual to breathe tested positive for COVID-19 close contact with a person with the above symptoms and or who tested positive for COVID-19 in the past 14 days none of the above
Please also discuss these symptoms with your internist (also known as general doctor or primary medical doctor).
Have you traveled outside of New York in the past 1 month? *

Yes No
Please specify where and when *
Please include state/province and country name.
Have you received the COVID vaccine?

Yes, I am fully vaccinated. Yes, I have received at least one dose and am going to receive a second dose soon. No, but I am scheduled to receive it soon. No, I am not able to due to another health condition. No, I have not due to personal preference/religious beliefs/other.
Please upload a copy of your COVID vaccination card. (optional)

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If you already uploaded your card on a previously completed form, you do not need to upload it again. Cancel of
Please indicate if you have a personal history of any of the below (choose all that apply) *

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

Yes No
Please indicate if you have a personal history of any medical/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/allergic rhinitis heart disease heart problems hepatitis type A hepatitis type B hepatitis type 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/psychiatric conditions. If no personal history, please write "none".
Family Medical and Psychiatric History *
Please include any medical/psychiatric conditions. If no family history, please write "none".
Do you have any family history of skin cancers (basal cell carcinoma, squamous cell carcinoma, melanoma, merkel cell carcinoma, etc.)? *

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 *
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."
Cosmetic Services
We offer many cosmetic services for the conditions above and more. Would you like to learn more about our most popular treatments?

Yes, please! No, thank you.
BOTOX® - BOTOX® helps to relax the muscles in the face and injections typically take only 15-30 minutes in-office, requiring no downtime--it is also a highly effective treatment for excessive sweating and underarm odor, no antiperspirant needed! Please note that if you are trying to conceive, pregnant, and or breastfeeding, you cannot receive BOTOX® injections.

Skin dermal fillers - Different from BOTOX®, fillers are made of a natural substance called hyraulonic acid and help to add volume to the treated areas. Injections typically take only 15-30 minutes in-office and require no downtime. We only use JUVÉDERM® and BELOTERO BALANCE®-brand fillers to ensure the most natural-looking results! Please note that if you are trying to conceive, pregnant, and or breastfeeding, you cannot receive dermal filler injections.

Chemical peel - Medical-grade chemical is applied in-office to the face or other areas for treatment to rejuvenate the skin and help decrease the appearance of blemishes--we typically recommend 3 sessions at 2 week intervals for the best results.

Cosmetic mole removal - The skin around the unwanted mole is numbed and then excised with a medical-grade razor. Dr. Khalil has successfully performed over 3,000 mole removals to date!

Milia (white spot) removal - Tiny cysts in the skin that can only be removed by a physician, the areas for treatment are numbed then incised and drained with our thinnest medical-grade needle.
Are you interested in any of the following cosmetic treatments? Please note that cosmetic treatments are not covered by medical insurances. Please also note that if you are trying to conceive, pregnant, and or breastfeeding, you cannot receive BOTOX® or dermal filler injections. *

BOTOX® to prevent and or treat fine lines and wrinkles BOTOX® for facial slimming and TMJ (lockjaw) treatment to the masseter BOTOX® for downturned lips or "gummy smile" correction BOTOX® to reduce sweating under the arms, on the hands, or on the feet BOTOX® to lift the eyebrows BOTOX® to treat "necklace lines" skin dermal fillers to treat flat/sunken cheeks or temples skin dermal fillers for chin enhancement skin dermal fillers to treat "laugh lines" skin dermal fillers for lip enhancement/texture correction skin dermal fillers for under eye (tear trough) lightening skin dermal fillers to treat depressed/atrophic acne scars chemical peel (for facial "glow," skin rejuvenation, and discoloration/hyperpigmentation from acne and other scars) sun/liver/age spot removal cosmetic mole removal dermatosis papulosa nigra (DPN) removal milia (white spot) removal red spot (cherry spot/hemangioma) removal skin tag removal torn earlobe repair none of the above
Medical Insurance
Accepted Medical Insurances:

-Aetna (including Meritain Health, Nippon Life Insurance, Trustmark, and other Signature Administrators)

-Blue Cross Blue Shield (except member ID prefix JLJ and/or Gatekeeper plans). Please note that if your insurance card says "EPO" a referral may be required.

-Centivo

-Cigna (including HealthPartners)

-EmblemHealth HIP (except Enhanced Care, Essential policies, and GHI). A referral is required for most HIP plans.

-Medicare

-Oscar

-UnitedHealthcare Liberty, Freedom, Choice Plus, and Choice policies only

We do not accept: GHI, Fidelis, Medicaid, Healthfirst, HealthShare plans (such as MultiPlan, PHCS, OneShare, Trinity HealthShare, etc.), or Worker's Compensation policies. We are not in-network with any Medicaid, including as a Medicare Supplement. If you have Medicaid as a Secondary Insurance/Medicaid Supplement, you must pay these charges out-of-pocket.

Please Note: If you have two insurances and or a Medicare Supplement, please list both in the correct order (or the insurance companies will deny your visit claim). If we are not in-network with your Secondary Insurance/Medicare Supplement and you do not have out-of-network benefits, you may receive a bill for which you are responsible to pay.

Referrals (important): All insurance cards that say HMO, PCP Selection Required, the name of your PCP (Primary Care Physician), Gated, Gatekeeper, Aetna Columbia Univerisity Student Health Plans, Centivo, and EmblemHealth HIP require referrals from your assigned PCP (Primary Care Physician). Also, many BCBS EPO plans require referrals. For Columbia students, this referral must be provided by a PCP at the Columbia University Student Health Center and submitted to Aetna by Columbia staff for processing. Referrals for Columbia students expire at the end of the applicable semester. For Centivo policies, this referral must be submitted electronically from the Centivo app by your assigned PCP. For EmblemHealth HIP policies, your assigned PCP must provide you with a valid referral on the EmblemHealth mandated referral sheet. Please note that generic referral slips are not considered valid by insurance companies and will be denied.
Has your insurance changed since your last visit? *

Yes No Unsure
Primary Insurance (please note that if we do not accept your insurance, you will be Self-Pay) *

Aetna (including Meritain Health, Nippon Life Insurance, Trustmark, and other Signature Administrators) Blue Cross Blue Shield (except member ID prefix JLJ or Gatekeeper plans). Please note that if your insurance card says "EPO" you may need a referral. Bright Health Centivo Cigna (including HealthPartners) EmblemHealth HIP (except Enhanced Care or Essential policies, not GHI). A referral is required for most HIP plans. Medicare (not Medicaid) Oscar UnitedHealthcare (Liberty, Freedom, Choice Plus, or Choice) Self-Pay
Primary Insurance (please note that if we do not accept your insurance, you will be Self-Pay) *

1199 Aetna (including Meritain Health, Nippon Life Insurance, Trustmark, and other Signature Administrators) Blue Cross Blue Shield (except member ID prefix JLJ and/or Gatekeeper plans). Please note that if your insurance card says "EPO" you may need a referral. Bright Health Centivo Cigna (including HealthPartners) Emblem Health HIP (except Enhanced Care or Essential policies) Medicare (not Medicaid) Oscar United Healthcare (Liberty, Freedom, Choice Plus, or Choice) Self-Pay
Insurance Policy Holder Legal Name *

First Name(s) and Middle Initial(s) if applicable Last Name(s)
Insurance Policy Holder Birthdate *

Month Day Year
Insurance Policy Holder Relationship to Patient (choose the option that best matches your relationship with this person) *
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 or upload them to your Patient Portal at www.dkdermatology.com/portal.
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, about half of all EPO plans, and most Student Health plans require referrals even if this is not written clearly on the insurance card. *

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 (Please note, if we are not in-network with your Secondary Insurance/Medicare Supplement and you do not have out-of-network benefits, you may receive a bill for which you are liable to pay. We are not in-network with any Medicaid, including as a Medicare Supplement. If you have Medicaid as a secondary insurance and still wish to see Dr. Khalil, you must pay these charges out-of-pocket.) *
Secondary Insurance Card (front) *

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Secondary Insurance Card (back) *

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Insurance Policy Holder Name *

First Name(s) and Middle Initial(s) if applicable Last Name(s)
Insurance Policy Holder Birthdate *

Month Day Year
Insurance Policy Holder Relationship to Patient (choose the option that best matches your relationship with this person) *
Medical Insurance Terms & Information
Copay - The fixed amount you pay for a health care service at the time of your visit.

Deductible - The amount you must pay out-of-pocket for healthcare before your insurance pays. If you have an unmet deductible, you will receive a bill after your visit even if we are considered a "covered, in-network physician". An office visit is usually several hundred dollars, and the exact price is determined by the insurance company and not by the provider.

Coinsurance - The percentage of healthcare costs you must pay once your insurer covers its share.

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: consultations, 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 skin steroids, skin paring, skin cyst drainage, and more. *

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 (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 billing). If my insurance company requires my biologic specimens to be sent to a specific lab, it is my responsibility to be aware of this and to inform the provider and their staff beforehand. *

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 all 5 boroughs and New Jersey. If you choose to use your own pharmacy, please remind the pharmacist to use manufacturer medication coupons (often found by searching Google for the medication name and the words "coupon card"). *

Yes, please send my scripts to Third Avenue Apothecary Pharmacy (free delivery to 5 boroughs and NJ, located at 1025A Third Ave, on 61st and Third Ave, (212) 230-1700, www.thirdaveapothecary.com) 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 all 5 boroughs 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"). *

Yes, please send my scripts to Third Avenue Apothecary Pharmacy (free delivery to 5 boroughs and NJ, located at 1025A Third Ave, on 61st and Third Ave, (212) 230-1700, www.thirdaveapothecary.com) No, please send my scripts to my pharmacy listed below.
Pharmacy Name *
Prescriptions are sent electronically to this pharmacy--we do not send paper scripts.
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 any 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: copays, deductibles, coinsurances, 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 to have a referral on the correct insurance form prior to my visit or I will be responsible for the entire visit cost. I understand that it is my responsibility to know if the physician and lab is a contracted in-network physician/facility recognized by my insurance plan, or I may be responsible for out-of-network charges. I understand that the provider does not accept and is not in-network with any Worker's Compensation-related insurance packages/polices or any Medicaid, including as a Secondary Insurance and or Medicare Supplement. I understand that if the provider is not in-network with my Secondary Insurance/Medicare Supplement, I may receive a bill for which I am liable to pay. I understand that the provider does not accept any HealthShare plans, including but not limited to MultiPlan, PHCS, OneShare, Trinity HealthShare, and more.

I agree that DK Dermatology PLLC may use my health information for diagnosis, treatment, payment, insurance billing, credit card payments and chargebacks, and other such healthcare operations. I consent to access and share my medical information with my insurance company, relevant medical providers (such as my Primary Care Physician/PCP), pharmacies, and hospitals via telephone, fax, email, and or voicemail.

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 telehealth/virtual visits are processed by insurance companies like in-person visits, and I may be responsible for any applicable copays, coinsurances, and deductibles. I understand that many but not all skin conditions can be diagnosed and treated through a telehealth/virtual visit, however, a telehealth/virtual visit is not as accurate as an in-person visit. Telehealth/virtual visits are not refundable.

By signing this form, I confirm that I understand the following definitions:

Copay - The fixed amount you pay for a health care service at the time of your visit.

Deductible - The amount you must pay out-of-pocket for healthcare before your insurance pays. If you have an unmet deductible, you will receive a bill after your visit even if we are considered a "covered, in-network physician". An office visit is usually several hundred dollars, and the exact price is determined by the insurance company and not by the provider or their office.

Coinsurance - The percentage of health care costs you pay once your insurer covers its share.

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.

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/consultation office visit.

I understand that it is my (the patient's) responsibility to schedule follow-up visits, especially if 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. I also acknowledge that it is my responsibility (the patient's) to inform my provider if I have had a blood draw, bacterial culture, viral culture, imaging procedure, skin biopsy, or other such procedure done and have not heard back from my provider in 10 business days or less with the results, as sometimes outside facilities do not always send results to the ordering provider in a timely manner.

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 (such as Hepatitis and Human Immunodeficiency Virus/HIV).

It is recommend for all adults to have (at least) yearly skin exams to check for skin cancer by a dermatologist and monthly self-skin checks. 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 (such as copays, coinsurances, and deductibles) by the 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 copay charges, insurance coinsurance charges, insurance deductible charges, or any other such charge) it is my responsibility to pay off this balance in a timely manner. If my bill is not paid in full by me and or my insurance company within 90 calendar 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 COVID-19/coronavirus, including cleaning the office, wearing masks, and screening for symptoms of coronavirus. However, it is not possible to guarantee a 0% risk of exposure. By coming into 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 COVID-19/Coronavirus
fever, chills, cough, fatigue, joint/muscle pain, headache, sore throat, congestion or runny nose, nausea, vomiting, diarrhea, loss of taste or smell (one of the earliest symptoms), shortness of breath, difficulty breathing, 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 COVID-19/coronavirus for at least 14 days before my visit.

I agree to wear a mask on the day of my visit. I agree to keep my mask on inside the office for the entire duration of my visit unless asked to remove/lower my mask by the physician or other staff.

I agree to not bring any guests or family members with me to my visit. I understand that I can instead include them by phone or video if applicable.

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

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Guardian Name (if other than the patient)

First Name Last Name
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