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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
Single
Married
Divorced
Widowed
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Country
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Home Phone
Cell Phone
*
Email
*
Referred By
Friend
News Paper
Previous Patient
Primary Care Doctor
Radio
Social Media
TV
Word of Mouth
Website
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
*
Private Pay
Traditional Medicare
Other
United Health
Humana
Aetna
Blue Cross Blue Shield
Enter Your 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
Spouse
Child
Same as Patient
Health Savings and/or Deductible Met
I have a Health Savings Account
Deductible Met
Insured Address
Secondary Insurance
*
No
Yes
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
*
Private Pay
Traditional Medicare
Other
United Health
Humana
Aneta
HCSC
Blue Cross Blue Shield
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
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
Select All
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
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