New Patient Registration Form

New Patient Registration

Please fill out all fields below.
Patient Name *

First Name Middle Name Last Name
E-mail
Sex
Date of Birth *

Month Day Year
Social Security Number
Marital Status

Patient Address: *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Home Phone Number

Area Code Phone Number
Cell Phone Number

Area Code Phone Number
Work Phone Number

Area Code Phone Number
May we leave detailed messages about your care on the following lines? *

Ok to leave message on home line Ok to leave message on cell Ok to leave message on work line I do not authorize McLean Dermatology to leave detailed messages about my care
Billing Information

Please bring a photo ID and your insurance card to your appointment.
Do you have active health insurance? *

Yes No
Name of Primary Health Insurance Company
Insurance ID Number
Name of Policy Holder

First Name Last Name
Policy Holder's Date of Birth

Month Day Year
Relationship to Policy Holder
If you are the main policy holder, please write SELF.
Name of Secondary Health Insurance Company (If applicable)
Secondary Insurance ID Number
Name of Policy Holder

First Name Last Name
Policy Holder's Date of Birth

Month Day Year
Relationship to Policy Holder
If you are the main policy holder, please write SELF.
Does your insurance require referrals to specialists? *

Yes No
Name of Referring Physician (If Applicable)
Please note: If your insurance requires referrals, you must obtain the referral prior to your visit.
Referring Physician Phone Number (If Applicable)

Area Code Phone Number
Name of Primary Care Physician
Primary Care Physician Phone Number

Area Code Phone Number
Preferred Pharmacy Name *
Preferred Pharmacy Phone Number *

Area Code Phone Number

Preferred Pharmacy Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

In case of emergency...
Emergency Contact:

First Name Last Name
Relationship
Contact Number

Area Code Phone Number
Please list the names and relationships of individuals who we may speak to about your medical records and billing matters related to your account.
Health History
Please list the names of any medications you currently take (including over-the-counter medications).
If you have a medication list, please feel free to upload a copy of it here:

Browse Files

Cancel of
Do you have drug allergies? Please list the names of medications you are allergic to here.
Do you have any of the following health conditions? Select all that apply. *

Anxiety Arthritis Atrial Fibrillation (Irregular Heartbeat) Cancer Depression Diabetes End State Renal Disease Hepatitis High Blood Pressure HIV/AIDS High Cholesterol Hyperthyroidism Hearing Loss Seizures Tuberculosis Psoriasis Eczema Hay Fever/Allergies Allergic to Topical Antibiotic Ointments Unintentional Weight Loss Yeast Infection with Antibiotics GI Upset with Antibiotics Problems with Bleeding Problems with Scarring (Hypertrophic Scars or Keloids) Immunosuppression Changing Mole Rash Abdominal Pain Bloody Stool Bloody Urine Chest Pain Cough Fever or Chills Headaches Joint Aches Muscle Weakness Muscle Stiffness Shortness of Breath Sore Throat Wheezing Thyroid Problems Pacemaker Defibrillator Artificial Joints within Past 2 Years Artificial Heart Valve Require Premedication Prior to Procedures Allergic to Latex Allergic to Adhesive Allergic to Lidocaine Currently taking Blood Thinners Planning a Pregnancy Currently Pregnant Breastfeeding Rapid Heartbeat with Epinephrine Organ Transplant Kidney Disease Liver Disease Coronary Artery Disease Former Smoker Current Smoker Alcohol Use Recreational Drug Use Tanning Bed Use None of these
Please list all other pre-existing health conditions
Please list all previous surgeries
Have you had skin cancer? *

No I have not had skin cancer Yes, history of Basal Cell Carcinoma (BCC) Yes, history of Squamous Cell Carcinoma (SCC) Yes, history of Melanoma
Has anyone in your family had skin cancer?

No family history of skin cancer Yes, family history of Basal Cell Carcinoma (BCC) Yes, family history of Squamous Cell Carcinoma (SCC) Yes, family history of Melanoma
Please specify which family members have had skin cancer.
Cosmetic Concerns

(Optional)
I would like to know more information about the following skincare products?

Eye Creams Sunscreen Retinols Cleansers Scar Creams Moisturizers Anti-Aging Serums Anti-Aging Moisturizers
I have the following cosmetic concerns:

Aging Skin Downturned Mouth Fine Lines/Wrinkles Age Spots/Brown Spots/Sun spots Skin Discoloration Under eye circles Unwanted fat on the belly/love handles/back/arms Crows Feet Loose Skin/Sagging Skin Loss of Facial Volume Uneven Skin Texture Acne Scarring Facial Redness Urinary Incontinence
I would like more information about the following cosmetic procedures:

Botox, Dysport, or Xeomin Anti-Aging Lasers (Fine Lines/Wrinkles) Fillers to Soften Facial/Hand/Neck Lines Lasers to Reduce Facial Redness Sclerotherapy (Spider/Varicose Veins) Latisse (Eyelash/Eyebrow Growth) Skin Tightening CoolSculpting Treatment Options for Excessive Sweating Kybella (Injections for Permanent Reduction of Chin Fat)
How did you hear about McLean Dermatology and Skincare Center? *

Family/Friend Insurance Company Physician Social Media Publication (medical journal, magazine article, etc.)
Should be Empty:

New Patient Registration

Billing Information

Health History

Cosmetic Concerns