New Patient – Unique Dermatology and Spa

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New Patient & New Returning Patient Registration

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.

Name*
First Middle Last
Gender*
- Male
- Female
Birth Date*
Date Format: 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
If you select "Private Pay" please mark "Insurance ID Number" and "Group Number" as "N/A" for not applicable.
Insurance Company*
Insurance ID Number*
Group Number*
Plan
Insured Employer
Insured Name*
Insured Date of Birth
Date Format: 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
Date Format: MM slash DD slash YYYY
Secondary Insurance Phone
Secondary Deductible
Secondary Health Savings Amount
Secondary Copay Amount
Secondary Co-Insurance Percentage
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 biosp for a suspicious growth
- Have visited tanning salons and/or do you sunbathe
- Have had skin cancer
- Interested in information about cosmetic procedure
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
- Select All
- Adhesive tape
- Antibiotics
- Aspirin
- Barbiturates or Sleep pills
- Codeine local anesthetics
- Latex
- Iodine
- Sulfa
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
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
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
Please check all that Apply
- Select All
- 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.
Date Format: MM slash DD slash YYYY

Unique Dermatology

2525 W Bellfort Ave #105-A, Houston, TX 77054

(713) 741-3376

info@mooreunique.com

New Patient & New Returning Patient Registration

Pharmacy Information

Employer Information

Emergency Contact Information

Insurance Information

Secondary Insurance Information

Medical History