Patient Information
Name_____________________________________
Date____________
SSN#________________________
Address____________________________ City_________________ State______ Zip_______
Home#__(
)______________ Cell#__(
Birth date ___/___/___
Sex:
( ) male
)______________ Work#__(
( ) female
)______________
Marital Status_________________
Referred By___________________________
Primary Physician______________________
Employer____________________________
Occupation__________________________
Emergency Contact___________________________Relationship________________________
Address___________________City/State/Zip_________________Phone__________________
Primary Insurance_____________________ Secondary Insurance ________________________
Policy Holder of Insurance
Responsible Party Name_____________________________________ Relationship__________________
Address_________________________ City/State/Zip________________________ Phone#__________
SS#_____________________ Birthdate________________ Employer____________________________
**Payments of co-pays & private pay fees are due at time of service. If remittance is not made by your insurance
company within 60 days after services are rendered, the balance will be forwarded to you.
**I herby authorize payment directly to that physician of the surgical and/or medical benefits. I also understand I am
responsible for any portion of the bill not covered by my insurance.
**I herby authorize release of information for insurance claim purposes; Photostat of the above is as valid as the
original. I understand all of the above and herby stated that the information is correct to the best of my knowledge. My
signature indicates that I have read the above and grant the request of authorization.
Signed____________________________________________
Office Use Only
Account Number ________
Self Pay ____
Copay _______
History and Intake Form
Past Medical History: (Please circle all that apply)
Anxiety
Arthritis
Artificial joints
Asthma
Atrial fibrillation
BPH
Breast Cancer
Colon Cancer
COPD
Coronary Artery Disease
Depression
Diabetes
End Stage Renal Disease
GERD
Bone Marrow Transplantation
Hearing Loss
Hypertension
HIV/AIDS
Hypercholesterolemia
Hyperthyroidism
Hypothyroidism
Leukemia
Lymphoma
Pacemaker
Prostate Cancer
Radiation Treatment
Seizures
Stroke
Valve Replacement
Other ______________________________________________________________________
Past Surgical History: (Please circle all that apply)
Appendix Removed
Bladder Removed
Mastectomy (Right, Left, Bilateral)
Lumpectomy (Right, Left, Bilateral)
Breast Biopsy (Right, Left, Bilateral)
Breast Reduction
Breast Implants
Colectomy: Colon Cancer Resection
Colectomy: IBD
Gallbladder Removed
Coronary Artery Bypass
PTCA
Mechanical Valve Replacement
Biological Valve Replacement
Heart Transplant
Knee Joint Replacement (Right, Left, Bilateral)
Hip Joint Replacement (Right, Left, Bilateral)
Kidney Biopsy
Kidney Removed (Right, Left)
Kidney Stone Removal
Kidney Transplant
Ovaries Removed: Endometriosis
Ovaries Removed: Cyst
Ovaries Removed: Ovarian Cancer
Prostate Removed: Prostate Cancer
Prostate Biopsy
Skin Biopsy
Basal Cell Cancer Surgery
Squamous Cell Carcinoma Surgery
Melanoma Surgery
Spleen Removed
Testicles Removed (Right, Left, Bilateral)
Hysterectomy: Fibroids
Hysterectomy: Uterine Cancer
Other________________________________________________________________________
Skin Disease History: (please circle all that apply)
Acne
Actinic Keratoses
Asthma
Basal Cell Skin Cancer
Blistering Sunburns
Dry Skin
Eczema
Flaking or itchy scalp
Hay Fever/Allergies
Melanoma
Poison Ivy
Precancerous Moles
Psoriasis
Squamous Cell Skin Cancer
None
Other_________________________________________________________________________
Do you wear Sunscreen?
Yes
No
Do you tan in a tanning salon? Yes
No
If yes, what SPF? ___________
Do you have a family history of Melanoma?
Yes
No
If yes, which relative(s)?
___________________________________________________________________
Medications: (Please list all current medications)
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Allergies: (Please list all allergies)
_____________________________________________________________________________________
_____________________________________________________________________________________
Social History: (Please circle all that apply)
Currently smokes
Drug Use
Smoked in the past
Never smoked
Dr. Roberts participates in E-Scripts. Below we need the following information
Pharmacy Name: __________________________________Phone number_________________
Pharmacy Address: ___________________________________Fax number_________________
Review of Systems: Are you currently experiencing any of the following?
(please check yes or no for the following)
Symptom
Yes
No
rash
changing mole
joint aches/ pain/ swelling
muscle weakness
hay fever/ seasonal allergies
fever/ chills
headache
night sweats
cough
shortness of breath
wheezing
anxiety
blurry vision
Other Symptoms:
________________________________________________________________________
Notice of Privacy Practices Acknowledgment
I understand that, under the Health Insurance Portability and Accountability Act of 1996 (HIPPA), I have
certain rights to privacy regarding my protected health information. I understand that this information
can and will be used to:



Conduct, plain, and direct my treatment and follow-up among the multiple healthcare providers
who may be involved in that treatment directly and indirectly
Obtain payment from third-party payers
Conduct normal healthcare operations such as quality assessments and physician certifications
I understand that this organization has the right to change its Notice of Privacy Practices from time to
time and that I may contact this organization at any tie to obtain a current copy of the Notice of Privacy
Practices.
I understand that I may request in writing that you restrict how my private information is used or
disclosed to carry out treatment, payment, or health care operations. I also understand you are not
required to agree to my requested restrictions but if you do agree then you are bound to abide by such
restrictions.
_______________________________________________________________ Date _________________
Signature of Patient or Parent/Guardian (if under 18)
Informed Consent to Dermatology Treatment
I have read the “Notice of Privacy Practice Regulations” and understand that my rights as well as the
doctors’ rights. I understand my rights to receive a paper copy of these rights as I have reviewed them. I
understand that you may disclose my medical information to other doctors’ offices when I am being
referred out to another physician. I understand that if I have a complaint in regards to any of my rights
violated, I may file a formal complaint. I agree to allow my doctor to exercise their right and disclose my
IIHI when required to do so by law.
Do not sign until you have read and understand the above consent.
I have read the above explanation of the HIPAA privacy act.
____________________________________________________Date_________
Signature of Patient or Parent/Guardian (if under 18)
I am granting Dr. Jennifer Roberts and staff to contact (Please print name) regarding my treatment
Name:__________________________DOB__________________ Contact number_________________
We want to make sure that all our patients get the best care possible. We would like you to tell us
your racial and ethnic background so that we can periodically review our patient data and make
sure that everyone is receiving the highest quality of care.
1. Do you consider yourself Hispanic/Latino?
Yes
No
Declined
2. Which category best describes your race? (Circle any you feel apply)
White
American Indian/Alaska Native
Asian
Black or African American
Native Hawaiian/Other Pacific Islander
Declined
ETHNICITY:
• Hispanic or Latino: A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish
culture or origin, regardless of race.
• Non-Hispanic or Latino: Patient is not of Hispanic or Latino ethnicity.
RACE:
• American Indian or Alaska Native: A person having origins in any of the original peoples of North and South
America (including Central America), and who maintains tribal affiliation or community attachment.
• Asian: A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian
subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine
Islands, Thailand,
and Vietnam.
• Black or African American: A person having origins in any of the black racial groups of Africa.
• Native Hawaiian or Other Pacific Islander: A person having origins in any of the original peoples of Hawaii,
Guam, Samoa, or other Pacific Islands.
• White: A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.