Calais Dermatology Patient Update Form

PERSONAL INFORMATION

Name Last: ______________________ First: _______________________ Middle: ________________

DOB: ___________ Age: ______ Sex: _______ Height: _______ Weight: _______ Race: _____________

SS #: ______________________________ Marital Status: ________________________

CONTACT INFORMATION

Mailing Address: ______________________________________________________________________

City/State/Zip: ________________________________________________________________________

Phone (Home): __________________ Cell: ____________________ Work: _______________________

Email Address: __________________________________ Preferred Contact Method: __ Home __Cell __Email

Emergency Contact Name: ______________________________________________________________

Number: _______________________________ Relationship: ___________________________________

PCP/ Referring Doctor Name: __________________________ Number: ___________________________

Preferred Pharmacy: ___________________________________________________________________

INSURANCE INFORMATION:

Primary Insurance: _________________________ Secondary Insurance: __________________________

Insurance Address: _________________________ Insurance Address: ___________________________

Name of Insured: __________________________ Name of Insured: _____________________________

Insured’s ID #______________________________ Insured’s ID #________________________________

Group # __________________________________ Group # ____________________________________

Employer Name: ____________________________Employer Name: _____________________________

Relationship of patient to the insured: __________ Relationship of patient to the insured: ___________

I authorize the release of medical information to my primary care or referring physicians, to

consultants if needed and as necessary to process insurance claims, insurance applications, and

prescriptions. I also authorize payments of medical benefits to the provider.

Patient/Guardian Signature: _______________________________ Date: _____________________

History and Intake Form

What is the nature of your visit?

_____________________________________________________________________________________

Past Medical History: (Please check all that apply)

__ None __coronary artery disease __ High Cholesterol

__Anxiety __ Depression __ Hyperthyroidism

__Arthritis __ Diabetes __ Hypothyroidism

__Asthma __ End Stage Renal __ Leukemia

__Atrial Fibrillation __ GERD __ Lung cancer

__ Bone Marrow __ Hearing Loss __ Lymphoma

__ BPH __ Hepatitis __ Radiation Treatment

__ Breast Cancer __ High Blood Pressure __ Seizures

__ Colon Cancer __ HIV/Aids __ Stroke

OTHER:

________________________________________________________________________________

Past Surgical History: (Please check all that apply)

__ None __ Kidney

__ Appendix (Appendectomy) __ Liver

__ Bladder (Cystectomy) __ Ovaries: Endometriosis

__ Breast: Biopsy __ Ovaries: Ovarian Cancer

__ Breast: Lumpectomy (Both, Left, Right) __ Ovaries: Ovarian Cyst

__ Breast: Mastectomy (Both, Left, Right) __ Ovaries: Tubal ligation

__ Colon (Colectomy): Colon Cancer Resection __ Pancreas: Pancreatectomy

__ Colon (Colectomy): Diverticulitis __ Prostate (Prostatectomy): Biopsy

__ Colon (Colectomy): Inflammatory Bowel Disease __Prostate (Prostatectomy): Cancer

__ Colon: Colostomy __Prostate (Prostatectomy): TURP

__ Gall Bladder (Cholecystectomy) __Rectum: (APR)

__ Heart: Biological Valve Replacement __ Rectum: Low Anterior Resection

__ Heart: Coronary Artery Bypass Surgery __ Skin: Basal Cell Carcinoma

__ Heart: Mechanical Valve Replacement __ Skin: Squamous Cell Carcinoma

__ Heart: PTCA __ Skin: Melanoma

__ Joint Replacement: Hip (Both, Left, Right) __Skin: Biopsy

__ Kidney: Stone Removal __Spleen (Splenectomy)

__ Kidney: Transplant __ Testicles (Orchiectomy)

__ Hysterectomy

Skin Disease History (please check all that apply including None)

__ None __ Dry Skin __ Poison Ivy

__ Acne __ Eczema __ Precancerous Moles

__ Actinic Keratosis __ Flaking or Itchy Scalp __ Psoriasis

__ Asthma __Hay Fever/ Allergies __ Squamous Cell Carcinoma

__ Basal Cell Carcinoma __ Melanoma

__ Blistering Sunburns

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 (*excluding Basal &Squamous Cell Carcinoma)

If yes, which relative(s): _________________________

Have you received your flu shot this year? ____ Yes ____ No

Have you received a Pneumonia shot in the past? ____ Yes ___ No

Medications: (please enter all current medication and dosage)

_____________________________________________________________________________________

____________________________________________________________________________________

Drug Allergies:

_____________________________________________________________________________________

Social History: (Please check all that apply)

Cigarette Smoking: Alcohol Use:

__ Currently smokes __ None

__ Former smoker __ Less than 1 drink per day

__ Never smoked __ 1-2 drinks per day

__ 3 or more drinks per day

Family Medical History: (Mother, Father, Brother, Sister, or Child) indicate with 1

letter.

Ex. Mother has heart Disease M

___ Heart Disease ____ Diabetes

___ High Blood Pressure ____ Stroke

___ Cancer ____ Other

Anything else we need to know:

_____________________________________________________________________________________

CALAIS DERMATOLOGY ASSOCIATES OFFICE POLICY

Insurance Card Policy: We require you to confirm that your insurance is current at each office visit. New patients

or existing patients with a change in their insurance information must provide a valid insurance card or temporary

print out at the time of the visit. Should you be unable to provide this documentation, you may pay in full at the

time of service and submit the claim to your insurance carrier for reimbursement. I understand by signing below I

am responsible for notifying Calais Dermatology Associates of any changes to my insurance.

Payment Policy: Co-Payments, Co-Insurance, Deductibles, and all outstanding balances are due and collected on

the day of my or my family’s appointment.

Account Balances: I am responsible for the timely payment of my account balances, co-insurance, and deductibles.

All balances are due in full within 30 days of my first billing. Any balance left unpaid after 90 days, without an

attempt at resolution, will be considered delinquent and may be submitted to a collection agency. If I am having

financial difficulty, I will call the billing office to discuss a payment plan.

Minor patients: A legal guardian must accompany children under the age of 18 to their initial appointment so that

the proper forms can be filled out and signed. Follow up visits do not require a guardian’s presence, unless a

procedure is being performed that requires a signed consent form.

Appointment Cancellations: If I am unable to keep my scheduled appointment, I will call Calais Dermatology to

cancel or reschedule my appointment. Surgical appointments require 48-hour cancellation notice. Regular and

Cosmetic appointments require 24-hour cancellation notice. Deposits for Cosmetic appointments are non-

refundable in the event the appointment is not cancelled 24 hours in advance.

Skin Biopsies: Calais sends all skin biopsies to Sagis Labs. Sagis provides us with comprehensive diagnostic and

prognostic information so we can accurately diagnose the disease, prescribe effective therapies, and initiate early

treatment options. If you would like your labs to be sent to a different lab, it is your responsibility to let the

nurse know at the time of your visit.

Patient/ Guardian Signature: _________________________________ Date: _____________________

By signing this form, I understand and agree to abide by Calais Dermatology Associates Office Policies on this form.

CALAIS DERMATOLOGY ASSOCIATES HIPAA POLICY

Patients over the age of 18 are protected under the Federal Health Insurance Portability and Accountability Act.

This Federal Law prohibits any staff member of Calais Dermatology from discussing appointments, medication, test

results or treatment plans with anyone other than the patient. If you would like to permit someone to discuss your

medical condition, confirm appointments or obtain results for you, please indicate their name(s) below.

Name of Individual (please print) Relationship to Patient

1._________________________________________ ________________________________

2. _________________________________________ ________________________________

I understand only the individuals listed above will be provided with information. Should I wish to change or delete

any of the names listed above, I will contact Calais Dermatology and request a Patient Update form.

Patient/ Guardian Signature: _________________________________________ Date: ________________

CALAIS DERMATOLOGY ASSOCIATES NOTICE OF PRIVACY PRACTICES

Patient Acknowledgement

I received and understood Calais Dermatology Associate’s Notice of Privacy Practices written in plain language.

This notice provides detail on how Medical Information about you may be used and disclosed and how you can get

access to this information. I understand that this practice reserves the right to change the terms of its Notice of

Privacy Practices. If changes to the policy occur, this practice will provide me with a revised Notice of Privacy

Practices upon request.

Patient/ Guardian Signature: __________________________________________ Date: ________________