21289 GwoodDerm First Appt info sheet - gwdermatology

1 GREENWOODDERMATOLOGYLarr y J. Buckel, . Th omas J. Eads , . Lau ra T. Stitl e, .92 South Par k Boulevar d Greenwo od, Indian a 46143 Offic e 317-889-7546 Fax 317-889-2482 www .g wde omThank you for choosing Greenwood dermatology for your Dermatologic are the experts in the diagnosis of skin, hair, and nail conditions, and are specially trained to provide the highest quality of medical, surgical and cosmetic you will find the paperwork that you will need to fill out and bring with you when you come in for your arrive 15 minutes before your scheduled appointment will need to bring with you:1.

2 Completed Insurance Card or Cards 3. Photo ID ( If minor, we will need parents ID)We recommend that you check with your insurance plan to be sure the doctor is in your address is, 92 South Park Blvd, Greenwood, IN on the reverse side of this look forward to helping you with your ,Larry Buckel MDThomas Eads MDLaura Stitle MD& StaffWe are located o I-65 at Exit 99 (Greenwood Exit)Go West on East Main St. to South Park Blvd. (McDonald s & Chase Bank are atthe corner of South Park and East Main St.)Go North (Right) on South Park are the rst building on the West side (Left) of the street past McDonald s(Same side of the road as the McDonald s)GreenwoodDermatologyPa tie nt Infor mationName of Bi rth: _____/_____/_____ Age :_____ Sex: Ma le Fe ma le Soc.

3 Securi ty #: _____Add ress:Mail ing Addres s: _____City: _____Sta te:_____Zi pCode:_____Home Phone :( )_____Ce ll Phone : ( )_____May weemail pers onal medical inf orma tion Ye s NoEm ai l:_____With my con se nt, Gree nwood Der ma tol ogy may mail to my home or ca ll my hom e or desi gnated loca tions any item s thatas sist the prac tice in car rying out trea tment, pa yment, and hea lthcar e ope rat ions such as appoi nt ment reminders,insuranc eite ms an dany cal lpert ai ni ng to myclinic al ca re, including labora tory resul ts among other s. Gr eenwood Dermato logy ha smyper miss ion to leav eames gnatu re:_____Plac eof employment:_____Phone : ( )_____Spouse splace of employment:_____ _____ Phone : ( )_____Em erge ncy Con tact InformationIn cas eof Em ergenc y, who shoul dbe notifi ed?

4 _____Phone ( )_____ _____Rel ati onship to pat ient: _____Pare nt, Sp ouse or Re spons ible Par ty(ifdifferentfrompatient)Name :_____Date of Birt h: _____/_____ s:_____ _____CityStateZip CodeHome Phone :( )_____Work Phone : ( )_____Physi cian Infor mation:Famil yPhysic ian_____Address:_____Were you ref err ed by aphysici an? _____ Ifyes, who is the refe rring ph ys ician:_____Addres sor phone number of ref erring physic ian:_____Insu ranc eInfor mation:Prima ry Insur ance Carr ier :_____Policyhol der sName: _____SSN# _____Bi rthdate _____Rel ations hip toPatient: _____Sec onda ry Ins uranc eCarrier: __ _____ _____Policyhol der sName: _____SSN# _____Bi rthdate _____Rel ations hip toPatient.

5 _____Pleasesignsowemayhaveyourinsurancea uthorizationonfileI aut hor ize any holder of medica l and/or other informationabout me to be re lea se d to the above insurancecompa ny(s), and any informa tion ne eded for this or a related insuranceclaim. I hereby assign to the physicianallpay me nts for medical service srendered to my dependentsor mys elf. Iunde rst and tha tIwil lbe billed and Iamre sponsibl efor any amount that isnot covered by my :_____/_____/_____Signat ure: _____PPlleeaassee pprreesseenntt yyoouurr iinnssuurraannccee ccaarrdd((ss)) aanndd aa pphhoottoo IIDD ttoo tthhee Toda y s Date: _____/ _____/_____((OOvveerr))Name_____ Date of Birth _____ Date_____ 1.

6 How were you referred to us? ____ Friend ____Doctor _____ Internet _____ Yellow Pages _____Other 2. Primary reason for today s visit?_____ 3. How long have you had the problem?_____ 4. What treatment have you tried both nonprescription and/ or prescription? _____ 5. Do you have or have you ever had any of the following: Review of Systems: (ROS)6. Current medication and dosage, include over the counter, and vitamins_____ _____ _____ _____(If you need additional space please check with the receptionist)7. Do you have any medication allergies? Yes _____ No _____ List: _____8.

7 Other Medical Conditions or Surgeries not already listed?_____ _____9. Any personal history of skin cancer? ____Yes ____No If yes, Type (If you know) _____10. Any personal history of other skin disease? ___Yes ___No If yes, What _____11. Any family history of skin cancer? ____ Yes ____ No If yes, What _____12. Any family history of skin disease? ____ Yes ____ No If yes, What _____13. Do you have any scarring tendencies after surgery? ____Yes ___No _____14. Women Only: Are you pregnant? ___Yes ___No If yes, Due Date _____ When was your last menstrual period? _____ For Office Use Reviewed by.

8 (1) _____ Date Signature (2) _____ Date Signature (3) _____ Date Signature (4) _____ Date Signature (5) _____ Date Signature (6) _____ Date Signature (7) _____ Date Signature (8) _____ Date Signature (9) _____ Date Signature(10) _____ Date Signature (11) _____ Date Signature (12) _____ Date Signature (13) _____ Date Signature (14) _____ Date Signature (15) _____ Date Signature(16) _____ Date Signature(17) _____ Date Signature(18) _____ Date Signature(19) _____ Date Signature(20) _____ Date SignatureDERMATOLOGY HISTORY FORMC ompleted By.

9 ___ Patient ___Parent/ Guardian _____ SignatureSYSTEMICYes No___ ___ Diabetes___ ___ Thyroid trouble___ ___ Kidney or bladder problems___ ___ Stomach or bowel problems___ ___ Hepatitis, jaundice, liver disease___ ___ Convulsions or epilepsy___ ___ Fainting___ ___ Glaucoma___ ___ Alcoholism___ ___ Hepatitis B Exposure___ ___ AIDS or HIV Exposure___ ___ Cancer___ ___ Blood Transfusion___ ___ Do you drink alcohol? If yes, How many:____per day, ____per weekLUNGYes No___ ___ Bronchitis___ ___ Emphysema___ ___ Asthma___ ___ Do you smoke_____ When was your last Flu shot?

10 VASCULARYes No___ ___ High Blood Pressure___ ___ Heart Attack___ ___ Heart murmur/Rheumatic Fever___ ___ Palpitation/Irreg. or fast heart beat___ ___ Heart disease, angina or chest pain___ ___ Artificial Pacemaker/Defibrillator___ ___ StrokeGreenwood dermatology 92 South Park Blvd Greenwood, IN 46143 317 889-7546 Patient Consent for Use and Disclosure of Protected Health Information I hereby give my consent for Greenwood dermatology to use and disclose protected health information (PHI) about me to carry out treatment, payment and healthcare operations (TPO). (Greenwood s Notice of Privacy Practices provides a more complete description of such uses and disclosures.)