New Patient Registration

Patient Name *

Patient Email *

Date of Birth *

Phone (H) *

Phone (C)

Address *

City *

Zip *

Referring Physician (if applicable) *

Physician Address

Physician Phone

Preferred Pharmacy

Pharmacy Address (or cross streets)

Pharmacy Phone

Reason for Visit *

Ethnicity
HispanicNon-Hispanic

Race (check one)
American Indian or Alaska NativeAsian/Asian AmericanBlack/African AmericanNative Hawaiian/Other Pacific IslanderWhiteOther

Primary Insurance

Subscriber (Insuranced)

Subscriber's date of birth

Relationship to Patient
SelfSpouseChildOther

Group #

ID #

Medical Claims Address

Customer Service Phone

Secondary Insurance

Secondary Subscriber (Insured)

Secondary Subscriber date of birth

Relationship to Patient (secondary)
SelfSpouseChildOther

Secondary Insurance Group #

Secondary Insurance ID #

Secondary Insurance Medical claims address

Secondary Insurance Customer service phone

Do you have a family history of skin cancer? *
YesNo

Family History of Malignant Melanoma? *
YesNo

Do you have a personal history of skin cancer? *
YesNo

Personal History of Malignant Melanoma? *
YesNo

Do you have a personal history of any other skin problem, such as eczema, psoriasis, dry skin, etc? If yes, please explain: *

Do you have any allergies to medications? If yes, please explain: *

Please select any of the following that apply to you:
High blood pressureDiabetesHeart diseaseHistory of strokeThyroid disordersProblems with easy bleeding/bruisingProblems with healing/scarringSuspicious lesions or changing molesHistory of blood clot/DVTAllergy to adhesive or bandagesAllergy to topical antibiotic ointmentsAllergy to lidocaineArtificial joints within past two yearsBlood thinnersRapid heart beat with epinephrine or a numbing shotPacemakerDefibrillatorArtificial heart valvePregnancy or planning a pregnancyBreastfeedingRequire antibiotic prior to procedures (due to heart valve or other condition)Tuberculosis

Do you use sunscreen? *
YesNo

Do you smoke? *
YesNo

Do you use chewing tobacco? *
YesNo

Have you ever used tobacco products? *
YesNo

Have you had a Pneumonia vaccine? *
YesNo

Please list all medications: *