New Patient Form | Hermitage Dermatology you for choosing our practice for your dermatology needs. Our providers and staff are . committed to providing you with the best possible care.

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PATIENT INFORMATION

Date=----~---

First Name: ___________Ml:___Last Name:___________

Date of Birth: Sex: [ ] Male [ ] Female

Address:_____________City,State, Zip: ____________

Home Phone: __________Cell Phone:, _______________

Work Phone: Email Address: _____________

Marital Status: [ ] Single [ ] Married [ ] Widowed [ ] Divorced [ ] Other

Primary Care Physician Name, City,State: ___________________

Emergency Contact

Name:_________________Relationship:._________

Phone Number: Alt Phone Number:

Respon s i b I e Party (if not patient)

Name:_________________Relationship:._________

Address:._______________City,State,Zip:.___________

Primary Insurance {Please complete & present ins. cards to Receptionist.)

Insurance Company: __________________________

Policy ID Number:_____________Group Number: _________

Name of Policy Holder: _____________DOB:__________

Secondary Insurance (if applicable)

Insurance Company: __________________________

Policy ID Number:_____________Group Number: _________

Name of Policy Holder: _____________DOB:,__________

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Patient Name: _____________DOB:_____

Past Medical History: (please circle all that apply)

Anxiety Coronary Artery Thyroid Problems Arthritis Disease Leukemia Asthma Depression Lung Cancer Atrial fibrillation Diabetes Lymphoma Bone Marrow End Stage Renal Prostate Cancer Transplantation Disease Radiation Treatment Breast Cancer GERO Seizures Colon Cancer Hearing Loss Stroke COPD Hepatitis

High Blood pressure NONE HIV/ AIDS High Cholesterol

Other ____________________________

Past Surgical History: (please circle all that apply)

Appendix Removed Joint Replacement within last 2 years Bladder Removed Kidney Biopsy (Nephrectomy) Mastectomy (Right, Left, Bilateral) Kidney Removed (Right, Left) Lumpectomy (Right, Left, Bilateral) Kidney Stone Removal Breast Biopsy (Right, Left, Bilateral) Kidney Transplant Breast Reduction Ovaries Removed: Endometriosis Breast Implants Ovaries Removed: Cyst Colectomy: Colon Cancer Resection Ovaries Removed: Ovarian Cancer Colectomy: Diverticulitis Prostate Removed: Prostate Cancer Colectomy: IBO Prostate Biopsy Gallbladder Removed TURP (Prostate Removal) Coronary Artery Bypass Spleen Removed Mechanical Valve Replacement Testicles Removed (Right, Left, Biological Valve Replacement Bilateral) Heart Transplant Hysterectomy: Fibroids Joint Replacement, Knee (Right, Left, Hysterectomy: Uterine Cancer Bilateral) Joint Replacement, Hip (Right, Left, NONE Bilateral)

Other

Patient Name: _______ _______DOB:_ ____

Skin Disease History: (please circle all that apply)

Acne Dry Skin Poison Ivy Actinic Keratoses Eczema Precancerous Moles Asthma Flaking or Itchy Scalp Psoriasis Basal Cell Skin Cancer Hay Fever/ Allergies Squamous Cell Skin Blistering Sunburns Melanoma Cancer

NONE

Other ____________________________ _

Do you wear Sunscreen? Yes No If yes, what SPF? ___ _ Do you tan in a tanning salon? Yes No

Do you have a family history of Melanoma? Yes No If yes, which relative(s)? ____ ___ ______________

Medications: (Please enter all current medications)

Allergies: (Please enter all allergies)

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Patient Name: _____________.DOB:_____

Social History: (Please circle all that apply)

Cigarette Smoking: Alcohol Use:

NoneCurrently Smokes Less than 1 drink per dayHas smoked in the past 1-2 drinks per dayNever smoked 3 or more drinks per dayFormer Smoker

Other

Family History (Only first degree relatives)

Preferred Language: _ _______ _

Ethnic Group: _________Race:--------

Preferred Pharmacy Name: ________ _

Phone#: __________

City or Zip code: _______

Patient Name: ______________D0B:_____

Review of Systems: Are you currently experiencing any of the following? (Please check yes or no for the following)

Hay Fever Chest Pain

Yes No Symptom Yes No

Fever/Chills 1Night Sweats·-· Unintentional Weight Loss Tehyroicl Pr.0bleins· Anxiety Depression · Abdominal Pain

Other Symptoms: ________________________

ALERTS: (please circle all that apply)

Allergy to adhesive Allergy to lidocaine Allergy to topical antibiotics Artificial heart valve Artificial joint replacement Blood thinners Defibrillator MRSA Pacemaker Require antibiotics prior to a surgical procedure Rapid heart beat with epinephrine

Are you pregnant or currently trying to get pregnant? Yes No

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Hermitage Dermatology Financial Policy Thank you for choosing our practice for your dermatology needs. Our providers and staff are committed to providing you with the best possible care. Please understand that payment is considered part of your treatment. The following is our Financial Policy which we require you to read and sign prior to any treatment.

Payment We accept the following forms of payment: Cash, Check, Visa, MasterCard, American Express and Discover. Payment for services is due at the time services are rendered unless prior arrangements have been made with our office. We understand that temporary financial problems may affect timely payment of your balance. We encourage you to communicate any such problems to our Office Manager, so that we can assist you in management of your account with a payment plan. Please note the parent that accompanies the minor child/children to the appointment is responsible for any payment due.

Insurance

Your insurance policy is a contract between you and your insurance company. We are not a party to that contract. Our relationship is with you. We are credentialed with most insurance carriers. Please present your insurance card at the front desk so that we can file a claim on your behalf. All charges are your responsibility whether your insurance company pays or not. Please be aware that not all services are a covered benefit in all contracts. Some insurance companies and some employers decide what a covered benefit is and what is not. Patients are encouraged to check with their insurance carrier regarding benefits and coverage prior to their appointment. Fees for these services along with unmet deductibles and co-payments are due at the time of treatment. Our practice is committed to providing the best treatment for our patients and we charge what is usual and customary.

Check Processing

I give permission to Hermitage Dermatology (Lynn A. Colaiacovo, M.D., P.C.) to convert any paper check to an electronic transaction.

Authorization & Acceptance of Financial Policy I authorize release of information concerning my (or my child's) health care, advise and treatment provided for the purpose of evaluating and administering claims for insurance

benefits. I also hereby authorize payment of insurance benefits otherwise payable to me

directly to Lynn A. Colaiacovo, M.D. PC. I understand that I am financially responsible for any balance not covered by my insurance. I certify that the information given by me in applying for payment is correct. I request that payment of authorized benefits be made on my behalf. A photocopy of these assignments shall be valid as the original.

Printed Patient Name: DOB:

Signature of Patient or Personal Representative: _________________ Relationship to Patient: _____________Date:___________

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Acknowledgment of Not ice of Privacy Pract ices and Disclosure of Protected Health

Information

By signing the ac~nowledgement to the Notice of Privacy Practices and Disclosures of Protected

Health Information, I further authorize Hermitage Dermatology (Lynn A. Colaiacovo, M.D., P.C.)

to allow the following :

To leave a detailed message on my answering machine or on my voicemail. [ ] YES [ ] NO

To send me information via text message. [ ] YES [ ] NO

To send me information via e-mail. [ ] YES [ ] NO

To discuss my condition with the person(s) listed below. [ ] YES [ ] NO

Name:_______________ Name:_______________

(First & Last) (First & Last)

Name: Name: (First & Last) (First & Last)

By signing this page you agree to allow Hermitage Dermatology (Lynn A. Colaiacovo, M .D., P.C.)

to disclose your health information with those you have indicated above, and the means in

which we may leave information for you. Also, you acknowledge that you have received a copy

of the "Notice of Privacy Practices" .

Signature of Patient or Personal Representative: _________________

Relationship to Patient:__________________________

Printed Name: Date : ----------------- ·-----------

Patient Name: DOB:

FOR OFFICE USE

Changes to above authorized by the patient over the phone:

Change Date Staff Initials