Name: _______________________________________Age: ___________ Date of Birth: _____________________
Referred By: Dr. ___________________________________ Patient Name: ________________________________
Primary Care Physician: Dr.______________________________Phone: ___________________________________
Reason for Visit: _______________________________________________________________________________
Duration of Problem: _________________________ Treatment: ________________________________________
Aggravating factors: ____________________________________________________________________________
Current Medications (please include OTC, herbs, vitamins, supplements): ________________________________
_____________________________________________________________________________________________
Allergies:
 None Penicillin Sulfa Tetracycline  Doxycycline  Codeine  Latex
 Other ________________
Have you ever had any bad reaction to local anesthesia?
No Yes  Never had anesthesia
SKIN CONDITIONS:
When you are exposed to the sun, do you:
Tan
 Burn Tan & Burn
Have you ever had skin cancer?
 No
 Yes
If Yes,
Basal Cell Cancer
 Squamous Cell Cancer
Melanoma
Where? _______________________When? _________________________ Treatment? ________________
Has anyone if your family ever had skin cancer?  No
Yes
If Yes,  Basal Cell Cancer Squamous Cell Cancer
 Melanoma Who? ______________________
Do you have a history of any skin problems or diseases?  No
 Yes
If Yes,  Psoriasis  Eczema Keloid Other______________________________
Past Cosmetic Treatments: Botox  Restylane  Juvederm  Radiesse  Sculptra  Collagen Facelift
Chemical Peel  Laser, type_______________________Other _______________________
PAST SURGERIES (Type and Date):____________________________________________
PAST MEDICAL HISTORY AND REVIEW OF SYSTEMS:
Constitutional:
Cardiovascular:
Ears/Eyes/Nose:
Endocrine:
Gastrointestinal:
Hematologic:
Infections:
Musculoskeletal:
Neurological:
Respiratory:
Psychiatric:
Others:
 Normal
 Normal
 Weight loss/weight gain  Fever/Nightsweats  Fainting
 Artifical Heart Valve
 Pacemaker
Chest Pain/Heart attack
Mitral Valve Prolapse
Irregular Heartbeat  Other _____________
 Normal
Glaucoma
 Glasses/Contacts
 Other ________________
 Normal
 Diabetes
 Thyroid Disease
 Other ________________
 Normal
 Reflux
 Liver Problem
 Other ________________
 Normal
 Anemia
 Bleeding Problems
 Other ________________
 Normal
HIV
 Hepatitis
 Other ________________
 Normal
Arthritis
 Artificial Joint
 Other ________________
 Normal
Stroke
 Seizures/Epilepsy
 Other ________________
 Normal
 Asthma
 Emphysema
 Other ________________
 Normal
Depression
 Anxiety Attacks
 Other ________________
 Kidney Problems
 Cold Sores
 Varicose Veins
 Eczema
 Psoriasis
 Other _________________________
Marital Status S M D W Occupation __________________________________
Smoking?
No
 Former  Yes, packs/day _________________
 FOR WOMEN ONLY: Are you currently pregnant, trying to become pregnant, or are you nursing?_____
Completed by:
FAMILY HISTORY:
SOCIAL HISTORY:
Patient
___________________________________ Date _________________
Patient Signature
By signing, I am acknowledging that I have disclosed all of my health information known to me at this time, and all of my
other personal information is adequate. I understand that it is my obligation and responsibility to notify Integrated
Dermatology of 19th St. of any changes in my medical during the course of my medical treatment.
 SIGNATURE______________________________________Date ___________________
General Office Information, Financial Policy, Insurance Affidavit, Cancellation Policy,
Telephone Policy, After-hours Policy, Signature on File
WELCOME TO INTEGRATED DERMATOLOGY OF 19TH ST. Thank you for giving us the
opportunity to take care of your dermatologic needs. We strive to provide you with elite
dermatologic care to meet all your skin needs and welcome any suggestions to enhance your
experience with us.
OUR POLICY REQUIRES PAYMENT AT THE TIME OF SERVICE. It is your responsibility to:
 Pay your co-pay at the time of service.
 Pay for services not covered by your insurance carrier.
 All HMO patients are responsible for obtaining and presenting their referrals at the
date of service. You may have to reschedule your appointment if referrals are not
presented.
 After your insurance has paid their portion, you will be billed for any co-insurance,
which is due upon receipt.
 Personal checks are accepted with proper identification (driver’s license or photo
ID). A $50 overdraft charge will be added to returned checks.
In the event that Integrated Dermatology of 19th Street, LLC has any portion of the fee
deducted as a result of my insurance not paying, I agree to pay that amount. If your bill is
unpaid, your account will be sent to a collection agency or an attorney to obtain payment.
You will be charged a fee of either $100 or 25% of the unpaid balance, whichever amount is
greater, to cover our costs for this action.
 SIGNATURE: _____________________________________ Date: _________________
CANCELLATION POLICY
• We require a 24 hour and one full business day cancellation notice for a scheduled
appointment.
• We require a 48 hour and two full business days cancellation notice for all surgical and
cosmetic appointments.
o PATIENTS WHO FAIL TO SHOW FOR THE SCHEDULED APPOINTMENTS
WITHOUT ADEQUATE NOTICE WILL BE CHARGE A $50 FEE FOR AN OFFICE VISIT
AND $100 FOR A SURGICAL AND COSMETIC APPOINTMENTS. THIS IS NOT
PAYABLE BY YOUR INSURANCE AND WILL BE CHARGED TO YOUR ACCOUNT.
I have read and fully understand my financial responsibilities under this policy.
 SIGNATURE: _________________________________Date________________________
General Office Information, Financial Policy, Insurance Affidavit, Cancellation Policy,
Telephone Policy, After-hours Policy, Signature on File (Continued)
TELEPHONE/AFTER-HOUR POLICY
 Telephone conversations with Dr. Chang under 15 minutes are complimentary.
Anything over 15 minutes will be charged at $50. This is not payable by your insurance.
 After hour conversations with Dr. Chang are complimentary for URGENT dermatologic
concerns. Non-urgent calls will be charged $50. This is not payable by your insurance.
BEST WAY TO CONTACT YOU:
 I hereby authorize the physician or their representative to leave laboratory, pathology
results, and confirmation of office appointments with:
 Home answering machine  Work Voicemail
 Email _____________________________
Mobile Phone
 Spoken with directly
AUTHORIZATION OF MEDICAL INFORMATION RELEASE

Do you give our office permission to discuss your medical information with other health
care providers and/or family members?
No Yes, If Yes, please provide
information below.
1. Name of person: ________________________________ Relationship: _________________
Phone (Day) ________________________ Phone (Evening) __________________________
Email _________________________________
2. Name of person/doctor: _________________________ Specialty: ____________________
Phone (Day) ___________________________ Email ______________________________
 I have read and fully understand my responsibilities under this policy.
 SIGNATURE: ______________________________Date_______________
HIPAA
PATIENT CONSENT FORM
Our Notice of Privacy Practices provides information about how we may use and disclose protected health
information about you. The Notice contains a Patient Rights section describing your rights under the law. You have
the right to review our Notice before signing this Consent. The terms of our Notice may change. If we change our
Notice, you may obtain a revised copy by contacting our office.
You have the right to request that we restrict how protected health information about you is used or disclosed for
treatment, payment, or health care operations. We are not required to agree to this restriction, but if we do, we
shall honor that agreement.
By signing this form, you consent to our use and disclosure of protected health information about you for
treatment, payment, and health care operations. You have the right to revoke this Consent, in writing, signed by
you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior
consent. The Practice provides this form to comply with the Health Insurance Portability and Accountability Act of
1996 (HIPAA).
The patient understands that:






Protected health information may be disclosed or used for treatment, payment, or health care operations
The Practice has a Notice of privacy Practice and that the patient has the opportunity to review this Notice
The Practice reserves the right to change the Notice of Privacy Practices
The patient has the right to restrict the uses of their information but the Practice does not have to agree
to those restrictions
The patient may revoke this Consent in writing at any time and all future disclosures will then cease
The Practice may condition receipt of treatment upon the execution of this Consent.
This Consent was signed by:
____________________________________________
Printed Name – Patient or Representative
X ____________________________________ __/__/__
Signature
Relationship to Patient
(if other than patient):
Date
____________________________________________
Witness:
____________________________________________
Printed Name – Practice Representative
X ____________________________________ __/__/__
Signature
Date
To all patients,
We ask that you provide us with your pharmacy information so that we may have it in our
system in order to benefit each patient's pharmacy prescription needs. Providing us with your
pharmacy information will expedite our communication and improve the efficiency with the
respective pharmacy carriers. This will ultimately help our patients get their prescriptions on
time.
Thank you for your cooperation.
DATE:
PATIENT NAME:
PHARMACY INFORMATION
Pharmacy Name *:
State:
City*:
Zip:
Address*:
Phone Number:
* MUST PROVIDE complete address information to ensure your prescriptions are sent to the
correct pharmacy.