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
Please upload a photo of a government issued ID. (If patient is under the age of 18 please upload a parent/guardian valid form of identification)

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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
Emergency Contact Information
Emergency Contact: *

First Name Last Name
Relationship to Patient *
Emergency Contact Number *

Area Code Phone Number
Billing Information

Please bring a photo ID and your insurance card to your appointment. Note: If you do not have insurance or are not using insurance for your visit, payment is due at the time of your visit.
Do you have active health insurance? *

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

First Name Last Name
Policy Holder's Date of Birth

Month Day Year
Patient's Relationship to Primary Insurance Policy Holder
If you are the policy holder, please write SELF.
Please upload a photo of the FRONT of your primary insurance card.

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Please upload a photo of the BACK of your primary insurance card.

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Name of Secondary Health Insurance Company (If applicable)
Secondary Insurance ID Number
Name of Secondary Policy Holder

First Name Last Name
Secondary Policy Holder's Date of Birth

Month Day Year
Relationship to Secondary Policy Holder
If you are the main policy holder, please write SELF.
Please upload a photo of the FRONT of your secondary insurance card.

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Please upload a photo of the BACK of your secondary insurance card.

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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. Referrals must be processed through your insurance and have an authorization number to be valid. Referrals may be faxed to us prior to your visit at(703) 388-0873 or emailed to info@mcleandermatologycenter.com.
Referring Physician Phone Number (If Applicable)

Area Code Phone Number
Your Care Team
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
Please list the names and relationships of individuals who we may speak to about your medical records and billing matters related to your account. (Please note: if no one is listed here, we will not be able to discuss your account with anyone other than you.) *
Health History
Please list the names of any medications you currently take, including over-the-counter medications. If you are not taking medications, please write "No medications." *
If you have a medication list, please feel free to upload a copy of it here:

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Do you have drug allergies? Please list the names of medications you are allergic to here. If you do not have drug allergies that you are aware of, please write "No known allergies." *
Do you have any of the following health conditions? Select all that apply. *

Abdominal Pain Allergy to Topical Antibiotic Ointments Allergy to Adhesive Allergy to Cow Milk Protein Allergy to Latex Allergy to Lidocaine Anxiety Arthritis Artificial Heart Valve Artificial Joints within Past 2 Years Atrial Fibrillation (Irregular Heartbeat) Bloody Stool Bloody Urine Breastfeeding Cancer Changing Mole Chest Pain Coronary Artery Disease Cough Currently taking Blood Thinners Defibrillator Depression Diabetes Eczema End State Renal Disease Fever or Chills GI Upset with Antibiotics Hay Fever/Allergies Headaches Hearing Loss Hepatitis High Blood Pressure High Cholesterol HIV/AIDS Hyperthyroidism Joint Aches Immunosuppression Kidney Disease Mastectomy - Left Side Mastectomy - Right Side Double Mastectomy Muscle Stiffness Muscle Weakness Organ Transplant Pacemaker Currently Pregnant Planning a Pregnancy Problems with Bleeding Problems with Scarring (Hypertrophic Scars or Keloids) Psoriasis Rapid Heartbeat with Epinephrine Require Premedication Prior to Procedures Rash Seizures Shortness of Breath Sore Throat Thyroid Problems Tuberculosis Unintentional Weight Loss Wheezing Yeast Infection with Antibiotics Tanning Bed Use Liver Disease Former Smoker Current Smoker Alcohol Use Recreational Drug Use None of these
Please list all other pre-existing health conditions, if applicable.
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 (Please write name in "Other" box) Insurance Company Physician Social Media Publication (medical journal, magazine article, etc.)
COVID-19 Liability Release Waiver
I understand that the novel Coronavirus (COVID-19) has been declared a global pandemic. I further understand that COVID-19 is extremely contagious and may be contracted from various sources. I understand COVID-19 has a long incubation period during which carriers of the virus may not show symptoms and still be contagious.

I understand that I am the decision maker for my health care. Part of this practice and team of health providers’ role is to provide me with information to assist me in making informed choices. This process is often referred to as “informed consent” and involves my understanding and agreement regarding recommended care, and the benefits and risks associated with the provision of health care during a pandemic. Given the current limitations of COVID-19 virus testing, I understand determining who is infected with COVID-19 is exceptionally difficult.
To proceed with care in consideration of the foregoing, I confirm and agree to the following: *

I understand my treatment may create circumstances, such as the discharge of respiratory droplets or person-to-person contact, in which COVID-19 can be transmitted and assume the risk that I may be exposed. I understand that, while I understand the potential risks associated with proceeding with a visit and/or treatment during the COVID-19 pandemic, I am opting electively to proceed with this visit and/or elective treatment that may not be urgent or medically necessary, and that I have the option to defer my treatment to a later date. I understand due to the frequency of appointments with patients, the attributes of the virus, and the characteristics of procedures, I may have an elevated risk of contracting COVID-19 simply by being in a health care office. I confirm have not experienced symptoms that of fever, fatigue, difficulty in breathing, dry cough, runny nose, sore throat, lost of taste or smell, or exhibiting any other symptoms relating to COVID-19 or any communicable disease within the last 14 days. I understand travel increases my risk of contracting and transmitting the COVID-19 virus that I have not, nor any member(s) of my household, traveled internationally, or domestically within the United states by air, bus, or train in the last 14 days. I have not, nor any member of my household, visited any any area within the United States that was reported to be highly affected by COVID-19, in the last 30 days. I have not been, nor any member(s) of my household, diagnosed to be infected of COVID-19 virus within the last 30 days. I am informed that this facility its staff have implemented preventative measures intended to reduce the spread of COVID-19. However, given the nature of the virus, I understand there may be an inherent risk of becoming infected with COVID-19 by proceeding with today’s consultation and/or treatment. I hereby acknowledge and assume the risk of becoming infected with COVID-19 through this elective visit and/or treatment and give my express permission to this practice and the staff to proceed with providing care. I understand that virtual telehealth options have been made available for medical consultations at this practice. I understand that if I would like a copy of this signed consent form, I may request one.
I knowingly and willingly consent to today’s visit and treatment with the full understanding and disclosure of the risks associated with receiving care during the COVID-19 pandemic. I confirm all of my questions were answered to my satisfaction. I have read, or have had read to me, the above COVID-19 risk informed consent to treat. I appreciate that it is not possible to consider every possible complication to care. I have also had an opportunity to ask questions about its content, and by signing below, I agree with the current or future recommendation to receive care as is deemed appropriate for my circumstance. I intend this consent to cover the entire course of care from all providers in this office for my present condition and for any future condition(s) for which I seek care from this office.

By signing this form I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that I may be exposed to or infected COVID-19 by my mere presence within the establishment and such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that th risk of becoming exposed to or infected by COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to, employees, volunteers, and program participants and their families. I hereby release McLean Dermatology and Skincare Center, LLC and Skinkure, LLC from any and all claims arising from or in connecting with any direct COVID-19 impact while visiting.
Patient Name *

First Name Last Name
Parent/Guardian Name if Patient is Under the Age of 18

First Name Last Name
Signature *

Clear
Date Signed

Month Day Year
Date
Should be Empty:

New Patient Registration

Emergency Contact Information

Billing Information

Your Care Team

Health History

Cosmetic Concerns

COVID-19 Liability Release Waiver