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(713) 741-33762525 W Bellfort Ave #105 Houston, TX 77054

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Unique Dermatology and Spa

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- Dermatology
- Cosmetic Surgery
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Moore Relief

Schedule Appointment

Home
Services
- Dermatology
- Cosmetic Surgery
Appointment
Products
Contact
Moore Relief

New Patient

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Home
Appointment
New Patient

Fields marked with an * are required
If you have not had an appointment in more than 2 years you are considered a new returning patient.

"*" indicates required fields

Patient Name*

First Middle Last

Gender*

Male

Female

Birth Date*

MM slash DD slash YYYY

Marital Status

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Cell Phone*

Email*

Referred By

Pharmacy Information

Pharmacy*

Primary Care Physician Phone*

Pharmacy Phone*

Address*

Street Name ZIP / Postal Code

Employer Information

Employer

Employer Occupation

Employer Phone

Emergency Contact Information

Emergency Contact Name*

First Last

Emergency Contact Phone*

Contact Relationship to Patient

Insurance Information

Insurance Company*

Enter Your Insurance Company

Insurance ID Number*

Group Number*

Plan

Insured Employer

Insured Name*

Insured Date of Birth

MM slash DD slash YYYY

Insurance Phone

Deductible

Health Savings Amount

Copay Amount

Co-Insurance Percentage

Relationship To Patient

Health Savings and/or Deductible Met

I have a Health Savings Account

Deductible Met

Insured Address

Secondary Insurance*

Secondary Insurance Information

Please Note: We will file your claim with your Secondary Insurance company, but you are responsible for paying the secondary amount. However, you will get a refund once the secondary insurance company pays.

Secondary Insurance Company*

Secondary Insurance ID Number*

Secondary Group Number*

Secondary Plan

Secondary Insured Employer

Secondary Insured Name*

Secondary Insured Date of Birth

MM slash DD slash YYYY

Secondary Insurance Phone

Secondary Deductible

Secondary Health Savings Amount

Secondary Copay Amount

Secondary Co-Insurance Percentage

Drivers License & Insurance Card

File Upload

Please upload an image of your Drivers License and Insurance Card (front and back of each)

Drop files here or

Accepted file types: jpg, gif, png, Max. file size: 15 MB, Max. files: 4.

Medical History

What brings you too the office?*

Please describe any previous skin problems you had*

Please check all that Apply*

Currently on Medication

Currently on blood thinners

Allergic to any medications

Have had a biopsy for a suspicious growth

Have visited tanning salons and/or do you sunbathe

Have had skin cancer

Interested in information about cosmetic procedure

N/A

Please list all the medications you are currently taken?*

Please list all the medications you are allergic to?*

Are you allergic to any of the following?*

Please check all that apply

Adhesive tape

Antibiotics

Aspirin

Barbiturates or Sleep pills

Codeine local anesthetics

Latex

Iodine

Sulfa

N/A

Do you have any of the Following?*

Please check all that apply

Abnormal moles

Acne

Bleed easily

Boils

Changes in moles

Chills

Cold sores

Dry skin

Eczema

Hives

Itching

Psoriasis

Rash

Rosacea

Scars

Sensitive skin

Sore that wont heal

N/A

Are any of the following in your past medical history?*

Please check all that apply

Aids/hiv

Alcoholism

Allergies

Anemia

Anxiety Disorder

Arthritis

Asthma

Bleeding Disorder

Blood Disease

Blood Transfusion

Bowel Disorder

Cancer

Depression

Diabetes

Eating Disorder

Epilpsy

Hay Fever

Heart Disease

Hepatitis A

Hepatitis B

Hepatitis C

High Blood Pressure

High Cholesterol

Joint Disodrer

Kidney Disorder

Liver Disorder

Lung Disease

Lupus

Measles

Migraines

Osteoporosis

Pace Maker

Rheumatic Fever

Skin Disorder

Stomach Ulcer

Stroke

Substance Abuse

Thyroid Disorder

Tuberculosis

Venereal Disease

N/A

Are any of the following in your past medical history?*

Please check all that apply

Abnormal Moles

Acne

Allergies

Arthritis

Asthma

Basal Cell Carcinoma

Cancer

Diabetes

Eczema

Melanoma

Psoriasis

Skin Cancer

Squamous Cell Carcinoma

N/A

Please check all that Apply

I've been hospitalize and/or had surgery

I regularly apply sunblock to exposed areas

I smoke

I use recreational Drugs

How much caffeine do you drink per day?

How much alcohol do you drink per week?

Preferred Date of Your Appointment*

You will be contacted within 48 hours to confirm your exact appointment time & day.

MM slash DD slash YYYY

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