Patient InformationOnly complete this form if you already have an appointment scheduled. Patient's Name * First Name Last Name Street Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone Number * (###) ### #### Email * Pharmacy Phone Number (###) ### #### Sex * Male Female Other Prefer not to say Date of birth * MM DD YYYY Age Marital Status Name of Spouse Emergency Contact * First Name Last Name Emergency Contact Relation * Emergency Contact Phone Number * Checkbox Male Female Other Prefer not to say Are you employed? Yes No If yes, what is your occupation? First Name Last Name Name of employer Employer Address Address 1 Address 2 City State/Province Zip/Postal Code Country Did your primary care physician refer you? Yes No Primary Care Physician Name First Name Last Name Primary Care Physician Phone Number (###) ### #### Primary Care Physician Address Address 1 Address 2 City State/Province Zip/Postal Code Country How did you hear about us? Did someone refer you? Option 1 Option 2 If yes, how were you referred? What is your primary insurance? * Please check * I understand that Ingleton Dermatology is out-of-network with my insurance plan. I am responsible for any charge(s) I incur. I understand some insurance carriers will only pay for services that are determined to be "medically reasonable and necessary." I understand that if my insurance carrier determines a particular service not to be "reasonable and necessary" they may deny coverage for that service. *If you provide an email address to us; we may email office correspondences and billing statements to you from time to time. If you do not want either of these, please check the box(es) below. I do not want office announcements or special notifications from the office emailed to me. I do not want statements emailed. What is the reason for your visit today? * List any chronic medical conditions List any known allergies to medication List any chronic medications that you are currently taking For women: Are you pregnant? Yes No Are you breast-feeding? Yes No Do you have a personal history of pre-cancers / atypical moles / skin cancers? * Yes No If "yes", what type? Do you have any prior history of chronic skin conditions? * Yes No If "yes" Psoriasis Eczema Other Other Is there a family history of skin cancer? * Yes No If known, please describe (i.e., family member, type of cancer) Any family history of skin conditions? * Option 1 Option 2 If yes, please list Do you have occupational sun exposure? * Yes No Past sun exposure * Low Moderate Significant Daily sunscreen used on face? * Yes No Review of Systems (check all that apply) Fever, weight loss Varicose veins Asthma or wheezing Stomach upset Swelling of feet, ankles, or hands Burning of eyes, glaucoma, cataract Changes in nails or hair Anxiety, depression Joint pains Seizures Hay fever Rash, itching Name of person filling out this form * First Name Last Name Relationship, if not patient Thank you! Please PRESS SUBMIT FIRST before clicking to read and sign the office policy form. This must be submitted prior to your appointment. Office Policies Form
