Patient First Name:    

        Middle Name:     

Patient Last Name:     Patients sex (male or female): Male Female

Date of Birth (month/Day/Full Year):         Patient's Social Security #:

If patient is a minor, what is parent's name?

Home Street Address:      Apt or Suite#:

City:      State:      Zip Code:

Home Phone:         Work Phone:      Cell Phone:

Email Address:

Are you single, married, divorced, widowed, separated, other? single     married     widowed     separated     other

Spouse's Name (if applicable):

------------------------------------------------------------------------------------------------

What is your occupation?     Are you retired (if yes, how long)?

    What is your work street address?     Work Suite #:

    Work City:     Work State:     Work Zip Code:

-------------------------------------------------------------------------------------------------

Whom shall we contact in case of an emergency (someone that lives at a different address than you)?

    Emergency Contact Name:     Contact phone # (must be different than your phone #):

    Relationship to you (i.e. friend, mother, father):

-------------------------------------------------------------------------------------------------

Who is your regular doctor?

What is your doctor's phone #?

Did a doctor refer you (if yes, please list who, their phone # and address below)? Yes    No

If a doctor did not refer you, whom may we thank for referring you?

    Yellow pages     Observer     The Florida Panthers     Relative (please list)     Friend (please list)

-------------------------------------------------------------------------------------------------

-------------------------------------------------------------------------------------------------

PATIENT MEDICAL HISTORY

It is extremely important to provide a complete medical history.  It is extremely important to provide a complete list of all medications and allergies.

List All Medications that the patient is allergic to:

Is the patient allergic to any of the following (please check all that apply)? Band-Aids     Mastisol     Neosporin, Polysporin, or Bacitracin     Tape     Adhesive     Latex     Lidocaine

List All Medications that the patient takes:

Does the patient take any of the following? aspirin (including baby aspirin)     Vitamin E     Ginko-Biloba     Motrin/Advil/ibuprofen     Aleve     blood-thinners

Have you taken Accutane within the past 18 months?   no         yes

--------------------------------------------------------------------------------------------------

Family History:

    Is the patient's mother? living   deceased?       If living, how old is she? If not, at what age did she die?

    Is the patient's father? living    deceased?       If living, how old is he? If not, at what age did he die?

    Do you have any children (if yes, list ages)?

Family and Personal Medical History:

For all of the following below, please check if any disorders apply for the patient, the patient's mother, the patient's father, or another blood relative.  Please provide explanations or as much information as possible.

    Allergic/Immunologic Problems (including HIV)-explain: patient     mother     father     other blood relative     explain:

    Arthritis/muscles/joint problems:   patient     mother     father     other blood relative      explain:

    Asthma:patient     mother     father     other blood relative      explain:

    Cancer, not including skin cancer (please tell which kind): patient     mother     father     other blood relative      explain:

    Diabetes ("sugar"):patient     mother     father     other blood relative      explain:

    Ears/Nose/Throat/Mouth Problems:patient     mother     father     other blood relative      explain:

    Eczema:patient     mother     father     other blood relative      explain:

    Hay Fever:patient     mother     father     other blood relative      explain:

    Headaches:patient     mother     father     other blood relative      explain:

    Heart (irregular heart beat, heart attack, bypass): patient     mother     father     other blood relative      explain:

    High Blood Pressure: patient     mother     father     other blood relative      explain:

    Kidney Problems: patient     mother     father     other blood relative      explain:

    Lung Disease:patient     mother     father     other blood relative      explain:

    Malignant Melanoma:patient     mother     father     other blood relative      explain:

        (note: for all patients with a history of melanoma, we will need a copy of all pathology reports at the time of your visit)

    Psoriasis:patient     mother     father     other blood relative      explain:

    Seizures:patient     mother     father     other blood relative      explain:

    Skin Cancer (please name type):patient     mother     father     other blood relative      explain:

    Stomach/Bowel Problems:patient     mother     father     other blood relative      explain: 

    Tuberculosis:patient     mother     father     other blood relative      explain: 

     -------------------------------------------------------------------------------

Please list all surgeries (including cosmetic--breast, nose, etc) and the approximate dates performed:

Females:  Are you pregnant  (if yes, how many months)?         If not, are you planning on getting pregnant (if yes, when)?

-----------------------------------------------------------------------------------

SOCIAL HISTORY

Do you live alone? yes    no      

Do you smoke? yes    no     If yes, how much?

Do you consume alcoholic beverages?  yes    no      If yes, what & how much?

Do you use recreational drugs or abuse prescription drugs?  yes    no      If yes, what, how much, how often?

What are your hobbies?

------------------------------------------------------------------------------------

------------------------------------------------------------------------------------

Would you like a complete skin examination/Skin cancer screening (requires one to get into a gown)? yes     no thanks.

------------------------------------------------------------------------------------

INSURANCE INFORMATION

Understanding one's heath care benefits can be confusing.  It is recommended that you contact your insurance company if you have any questions regarding your benefits or eligibility.  We will do our best in verifying one's benefits before one's visit, although this is not always possible and is not our responsibility.  This process may take up to 30 minutes or more.  For this reason, by providing this information now, you will reduce your wait time when you arrive to our office.

Which Insurance do you have?   Medicare only     Medicare with a supplemental insurance (NOT a Medicare HMO)     Aetna PPO     First Health     BC/BS (not an HMO or Health Options)     Dimension Health     Humana Gold     Humana HMO (not Gold)     Humana PPO or POS     Careplus     Beechstreet     BestChoice     None - I am a selfpay     I am not sure     Other - please type 

NOTE: if you do not have one of the listed plans above, we may not take your insurance.  It is recommended that you contact our office or your insurance company to ensure that we are a participating provider and verify your benefits BEFORE your visit with us.  For Medicare, we do accept assignment and we will assist in submitting claims to secondary carriers.  All Medicare patients are responsible for annual deductibles and 20% copays.  Most Medicare supplements are handled by our office including most BC/BS & AARP. 

What is your Insurance ID#:

Medicare patients do not need to fill in the 4 items below.  Medicare PPO or Medicare HMO patients should.

What is your Plan # (leave blank if none):

What is your Group # (leave blank if none):

What is the phone number on your insurance card for Providers (leave blank if none):

What is the phone number on your insurance card for members or member services:

What is the date of your appointment?

Initial- - I understand that I must provide 24 hours notice to cancel an appointment. If not, I will be charged a fee that I agree to be personally responsible for.

  Please print out your form confirmation and bring with you to the office.

You will not be able to submit this form unless you accept our cancellation policy - in red immediately above the submit button. Put your initials in the box above the submit button.