PATIENT INFORMATION

EMERGENCY CONTACT

MEDICAL INSURANCE (S)

I understand that I am responsible for all charges regardless of insurance coverage. I agree to pay my account with this office in accordance with the regular rates and payment terms of this office. In the event I am entitled to health insurance or other benefits relating to my medical condition and they are available to cover the costs of treatment provided by this office, I hereby assign those benefits to this office to be applied to my bill. The office my release record of my treatment to my insurance company or other third parties responsible for the payment of my medical charges.

PRIMARY CARE PHYSICIAN

PREFERRED PHARMACY

PAST MEDICAL HISTORY

PAST SURGICAL HISTORY

SKIN DISEASE HISTORY

SUNSCREEN

MELANOMA

CURRENT MEDICATIONS

CURRENT DRUG ALLERGIES

REVIEW OF SYSTEMS

SOCIAL HISTORY

HIPAA Authorization Form

(Permission from patient/patient’s legal guardian to share personal medical information)

hereby authorize A to Z Dermatology and/or associated medical facilities to release any and all medical information and test results that pertain to me, to the following individuals (s)

I authorize A to Z Dermatology and/or associated medical facilities to contact the individual(s) listed above to convey any pertinent information to me, in the event that I am unable to be reached by the facility.

I understand that I may revoke/cancel this authorization by notifying A to Z Dermatology in writing of my intent to revoke authorization or change the name(s) of the individuals to whom information is to be released.

Or if applicable: