New Patient Registration Form - Dermatology Practice

Patient Information

Full Name: _________________________________ Date: _______________ Date of Birth: _____________ Age: _____ Gender: ☐ M ☐ F ☐ Other Address: __________________________________________________ City: _________________ State: _______ ZIP: ____________ Phone: (Home) _____________ (Cell) _____________ (Work) _____________ Email: ____________________________________________________ Preferred Contact Method: ☐ Phone ☐ Email ☐ Text Emergency Contact: _________________ Phone: _________________

Insurance Information

Primary Insurance: ________________________________________ Policy Number: _________________ Group Number: _________________ Policy Holder Name: _________________ DOB: _________________

Medical History

Skin Conditions (check all that apply)

☐ Acne ☐ Eczema ☐ Psoriasis ☐ Skin Cancer ☐ Melanoma ☐ Other: _________________

Current Medications

Allergies

Medication Allergies: ______________________________________ Latex Allergy: ☐ Yes ☐ No Other Allergies: _________________________________________

Family History

Skin Cancer: ☐ Yes ☐ No Relationship: _________________ Melanoma: ☐ Yes ☐ No Relationship: _________________

Consent

I certify that the above information is accurate and complete to the best of my knowledge.

Signature: _________________________ Date: _________________