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
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. (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:

Browse Files

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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.)
Should be Empty:

New Patient Registration

Billing Information

Health History

Cosmetic Concerns