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NBme_:--_ _ _ _ _ _ _ _ _ _ _ _ _.....:.....-.-_ _~ _ _ _ _ _ _ _ _ ___::__::_::_-Today'sdate--

Home Phone L-.l_______ Work Phone ' - - _ - f_ _ _ _ _ Cell Phone Date of Birth SS #

' - - _ - 1 _ _ _ _ _ _ _ __

----------------- Marital Status ---Full

Part Time !'."tll,rtl'!ln:

SOlous:e's Name: ______________________ --.-"'-J


Person to contact ifwe are Wlllble to reach you ________________---,-_ _ _ _ Phone _ _ _ _ _ _ __ (please


May we leave II message on your machine? OY ON

May we leave II message for you at: work: to call us? OY ON

Would you like to occasionally receive infOrmation about skin prc,ce<hm~s and products that we offer? OY ON we discuss your medical condition with another person? OY ON lfyes, whmn _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Relationship _ _ _ _ __ How did Policy Holder

d1ffme:nt from

or responsible

Holder's Date of Birth Enltployer ofPolicy Patient's Relationship to Policy

If patient D a minor please enter responsible party tmonnatiOlIl. (Note: We do not bill absent parents; the

adult presenting the minor for care D the responsible party.)




I authorize my insumnce company to pay bene:fif5 on my behalf directly to Advanced Dermatology and Cancer Center.. I authorize this office to provide to my insmance company. my information necessary process claims for services rendered to me.

appears on your lDSlmmlOC


I authorize any holder of medical or other infmmation about me to release to the Social Securi:tY .Admi.nistmtion and Health Care Admini.stra:tion or its intermediaries or carrier any information neePed for this or a related Medicare claim. I permit a copy of this authorization to be used in place of the orig:inal, and request payment of medical benefits to the party who accepts Regulations pertaining to Medicare ofbenefits apply.

Slgtmtu:re as it appears on Medicare Card



UPI)J.eIne.r:ltBl policy and it a MEDIGAP to wnlCD. au1:omLati.callJl "crOE:lBe8 over!'. we are required to keep a separate signature on file:

I request autborized MEDIGAP benefits be made on my behalf for any services furnished to me. I any holder ofmedical . to release to my :MEDIGAP carrier any information needed to determine these ben~;mts or the benefits payable for :related services.

Sig:lmture as appears on MEDIGAP Card

Do you or your spouse work a company coverage through insurance at that job?

DY ON Are you<..........-I by any

has more than 20 empJDiyeE~B and have

mstiJIBnIOC that Makes Memcare secondary?

you for choosing Advanced Dermatology &

Cancer "".....


for your hea1thcare needs.

We are required by law to provide you with Ii copy of our Notice of Privacy To ensure that recqrds are accurate, please, sign this form and return it to our receptionist to acknowledge that you have been with a copy Notice.



Signatme of Patient (or Legal Representative)





Advanced Dermatology and Skin Cancer Center

Melody L Stone, M.D., FAAD

Mary Zahau FNP-C lindsay Delmont PA-C

care plans. Please

contracts with Medicare and with many This office check with our reception staff to determine whether your plan is one of these.

If we have a contract with your plan, we will file a claim with your insurance company. The amount for which you are responsible (any deductibles, copays, percentages, or non-covered services) is required at the time of service. If you do not have one of the plans with which the practice is contracted, the total is required atthe time of "''''.......,.'''

cost your If at any you are the cost of a proposed by the doctor, you may ask someone from the business office who will be happy to discuss the cost with you. For your convenience in paying, this office accepts MasterCard, Visa, Discover, and American addition to and In an effort to keep patient costs down, we are not able to extend credit. However, we do accept Care Credit. Please ask for someone from the business office or go to for more information. If you must cancel an appointment, please give us a 24 hour notice so we may schedule another patient who waiting. who continuously do not keep their appointments I and who do not call to cancel, may be released from the practice.

I certify the financial policy of Advanced Dermatology and Skin Cancer Center and agree to abide by the policy.

Advanced Dermatology & Skin Cancer Center

Patient Name: __________________________________________________________ Age: _______ Sex: _______ Date:_____/_____/________ Review of Systems Please check any of the following that you have now or have had recently: ___Fever/Chills ___Weight Changes ___ Heartburn Past Medical History Drug Allergies (List Reactions):________________________________________________________________________________________________ Other Allergies (food, seasonal, etc....):_________________________________________________________________________________________ Current Medications:_________________________________________________________________________________________________________ Do you take Aspirin? Yes No ___Herpes I (fever blisters) ___Herpes II ___Hepatitis ___HIV ___Tuberculosis ___Asthma ___Hayfever ___Eczema ___Reaction to local anesthesia Which is true for you? (check) Coumadin (warfarin)? ___Diabetes ___High Blood Pressure ___High Cholesterol ___Heart Attack ___Artificial Heart Valve ___Bad Veins ___Mitral Valve Prolapse ___Pacemaker ___Bruise Easily Yes No Ibuprofen? Yes No Plavix? Yes No Have you ever had any of the following? (Please Check) ___Seizures ___Anemia ___Thyroid Disease ___Arthritis ___Lung Disease ___Kidney Disease ___Eye Disease ___Liver Disease ___Other:________________ ___Always burn ­ Sometimes tan ___Never burn ­ Always Tan Sunscreen Use (check): Yes No ___Daily ___Sometimes ___Never Yes No Are you planning to become pregnant? (circle) Comments ___Malignant Moles ___Skin Cancer ___Scarring ___Bleeding Tendency ___Artificial Joints ___Organ Transplant ___Chemotherapy ___X-Ray Treatments ___Other:______________ ___Nausea/Vomiting ___Diarrhea ___Constipation ___Rash ___Skin Color Changes ___Nail Changes ___Itching ___Hair Changes ___Swelling Ankles

___Always burn ­ Never tan ___Sometimes burn ­ Always tan

How many blistering sunburns have you had? ________ Females Only: Are you pregnant? (circle)

Family History: Medical conditions that have occurred in your family (check): Other Blood Disease/Condition Mother Father Sibling Relative Allergies Arthritis Cancer Diabetes Eczema Heart Disease High Blood Pressure Lung Disease Malignant Melanoma Psoriasis Skin Cancer Tuberculosis Social History Occupation:______________________________ Do you smoke?: Yes No _____packs/day Initials _____ _____ _ _____ _ _____ _ Do you drink alcohol? Yes No

Hobbies/Leisure Activities:______________________________________________________ Do you use recreational drugs? Yes No Initials _____ _____ _ _____ _ _____ _ Date ___________ ___________ _ ___________ _ ___________ _

Office Use Only

Changes to Medical History ______________________________________ ______________________________________ _ ______________________________________ _ ______________________________________ _ Date ___________ ___________ _ ___________ _ ___________ _ Changes to Medical History ______________________________________ ______________________________________ _ ______________________________________ _ ______________________________________ _

_ _ _ _ _ _ Reviewed by Provider:_____________________________________________________________________ Date:_____________________________


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