DC DERMCARE

Patient Registration
Patient Information
Date*

MonthDayYear
Date
Patient's name:*
First Name
⠀
Middle Name
*
Last Name
Title:*

Mr.Mrs.MissMs.
Martial Status:*

SingleMarriedDivorcedSeparatedWidowed
Is this your legal name?*

YesNo
If not, what is your legal name?*
Former name:*
Birth date:*

MonthDayYear
Date
Sex:*

MaleFemale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Home Phone Number:*

Area CodePhone Number
Pharmacy’s Fax Number:

Area CodePhone Number
Additional Contact Information:
Cell Phone Number:*

Area CodePhone Number
Emergency Contact Name:*
Phone Number:*

Area CodePhone Number
Dermcare is allowed to leave voice mail messages for me on the phone number provided:*

YesNo
Dermcare will not share your email address or personal information with any third party and all information will be kept confidential as per the Ontario Freedom of Information and Protection of Privacy Act. We will communicate with you regarding your medical/surgical condition or advise you of advances in the treatments that might be of interest or benefit to you.
Dermcare is allowed to contact me at the email provided:*

YesNo
What is the purpose of your visit today?
How long have you had this condition?
Please indicate any other associated symptoms:
If you have any rash on your skin or your skin is broken out please complete the following:*

YesNo
Indicate Location:*
Treatment to Date:*
Does your skin tend to be oily or dry (select one or both, if applicable)*

OilyDry
When you are exposed to the sun do you tan or burn or burn and tan (select the one that applies)*

TanBrunTan and Burn
Have you ever had a blistering sunburn in your youth?*

YesNo
Past Medical History:
Please indicate if you have any medical problems with any of the following:
AsthmaDiabetesKidneyLupusHeart DiseaseHigh Blood Pressure
ThyroidArthritisFeverLiver DiseasePsoriasisM.S
Eczema as a childRheumatoid ArthritisCrohn's DiseaseIncreased CholesterolUlcerative colitisCancer
If cancer was indicated, what type?*
Do you have a pacemaker?*

YesNo
Do you have an artificial joint?*

YesNo
Do you have an artificial heart valve?*

YesNo
Medications:
List all prescriptions, over the counter or herbal medications you take: *
Do you take:

ASAAnti-InflammatoryWarfarinPlavix or similar
Have you taken Aspirin in the last 48 hours?*

YesNo
Do you have any medication allergies?*

YesNo
(if yes. please list)*
Do you take antibiotics before going to the dentist?*

YesNo
(if yes, why?)*
Do you take blood thinners?*

YesNo
(if yes, why?)*
Family History:
Are there any diseases that run in your family?*

YesNo
If yes, please list*
Do you have any of your blood relatives Have any of the following?
Skin cancer?*

YesNo
Relationship*
Melanoma?*

YesNo
Relationship*
Psoriasis?*

YesNo
Relationship*
Eczema?*

YesNo
Relationship*
Asthma?*

YesNo
Relationship*
Scarring Acne?*

YesNo
Relationship*
Pancreatic cancer?*

YesNo
Relationship*
Autoimmune Disease (example: Lupus, M.S)*

YesNo
Relationship*
Social History:
What type of work do you do? Occupation:*
Do you smoke?*

YesNo
Amount per day*
Do you drink alcoholic beverages on a regular basis?*

YesNo
Amount per day*
Review of Systems:
Do you have any current or past problems with any of the following? (If no, leave blank)
General health / Skin
Eyes / Ears / Nose / Mouth
Heart / Liver / Lungs / Kidneys
Throat / Stomach / Bowel
Headaches / Seizure
Psychological Disorder
Thyroid / Diabetes
Blood / Bleeding Disorder
Female: Are you pregnant or planning to become pregnant?*

YesNo
Please check any of our cosmetic dermatology services about which would you be interested in:
Laser Hair RemovalAcne Scars TreatmentsSkin Tags RemovalFacial Skin TighteningWrinkles TreatmentsStretch Marks TreatmentsBotoxFillers
Eyelashes Enhancement (Lattisse)MicrodermabarsionChemical PeelRemoval of Moles/CyctsWild Opening PoresSpider Veins RemovalBotox for Excessive SweatingSkin Care Products
I understand that possible exposure to COVID-19 before/during/after my treatment / procedure / surgery may result in the following: a positive COVID-19 diagnosis, extended quarantine / self-isolation, additional tests, hospitalization that may require medical therapy, Intensive Care treatment, possible need for intubation / ventilator support, short - term or long-term intubation, other potential complications, and the risk of death. In addition, after my elective treatment / procedure/surgery, I may need additional care that may require me to go to an emergency room or a hospital.*
Initials
Home Phone Number:*

Area CodePhone Number
Work Phone Number:*

Area CodePhone Number
Date*

MonthDayYear
Date
Patients' / Guardian's Signature

Clear
Should be Empty:

Patient Registration

Patient Information