PATIENT MEDICAL HISTORY

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1 PATIENT MEDICAL HISTORY Last Name First Name M.I. D.O.B / / Age Primary Care Physician and Lcatin: Pharmacy (name, city, and street): Whm can we thank fr yur referral? Facebk Instagram Friend Dctr Insurance Other: Are yu interested in any f the fllwing services? Btx Filler Laser Hair Remval Skin Care Prducts Pht Rejuvenatin Chemical Peels SculpSure Other: PAST MEDICAL HISTORY YES NO Eczema Psriasis Diabetes Heart disease Thyrid disease Sexually transmitted diseases Cancer (ther than skin) High bld pressure High Chlesterl Tuberculsis Other cnditins (please list): MEDICATIONS (name and dse) ALLERGIES (please list with reactins) SOCIAL HISTORY YES NO D yu smke? SKIN CANCER/FAMILY HISTORY Have yu ever had basal cell r squamus cell carcinma (BCC r SCC)? Date/lcatin/treatment SURGICAL HISTORY YES NO D yu take Cumadin, Plavix, Pradaxa, Xarelt, Eliquis, aspirin, fish il, r ther bld thinners? If yes: D yu have any artificial jints, heart valves, r ther implanted material? If yes, please list: D yu rutinely take antibitics befre dental prcedures? YES NO Have yu ever had melanma? Date/lcatin: Any family members with melanma? Date/lcatin: Any family members with ther skin cancer? List: Have yu ever had a reactin t anesthesia? D yu have liver r kidney disease? D yu have a bleeding r cltting disrder? D yu have a pacemaker r defibrillatr? Versin: Rt. 38 Suite 8 Hainesprt NJ P: F: inf@barattadermatlgy.cm

2 Surgeries (please list year perfrmed) REVIEW OF SYSTEMS Fr each questin, check yes r n CONSTITUTIONAL YES NO MUSCULOSKELETAL YES NO Fever r chills Muscle weakness Weight lss Neck stiffness Night sweats Jint aches PSYCHIATRIC Shrtness f breath Depressin Cugh Anxiety Wheezing NEUROLOGIC Headache Abdminal pain Seizures Bldy stl/urine CARDIOVASCULAR Chest pain Prblems with bleeding ALLERGIC/IMMUNOLOGIC Immunsuppressin Thyrid prblems Hay fever EYES Sre thrat Blurry visin Please list any family members r ther individuals we can discuss yur medical infrmatin with ther than yurself. Please include their full name, relatinship, and phne number. T the best f my knwledge, the abve infrmatin is accurate and cmplete. Patient Signature: DATE: Versin: Rt. 38 Suite 8 Hainesprt NJ P: F: inf@barattadermatlgy.cm

3 HIPAA / Patient Cnsent fr Use and Disclsure f Prtected Health Infrmatin I hereby give my cnsent fr Baratta Dermatlgy t use and disclse Prtected Health Infrmatin (PHI) abut me in rder t carry ut health care treatment and payment peratins. (The Ntice f Privacy Practices prvided herein by Baratta Dermatlgy describes such uses and disclsures mre cmpletely. T learn mre abut HIPAA, yu may visit the website fr the US Department f Health and Human Services at: I have the right t review the Ntice f Privacy Practices prir t signing this cnsent. Baratta Dermatlgy reserves the right t revise its ntice f Privacy Practices at any time. A revised Ntice f Privacy Practices may be btained by frwarding a request t Baratta Dermatlgy. With this cnsent, I agree and acknwledge that Baratta Dermatlgy may: Call, , text, and/r leave messages n vice mail at the numbers and I have prvided Baratta Dermatlgy regarding appintment reminders, insurance and billing items, and any ther matters pertaining t my clinical care, including test results, etc. Speak t certain persn(s) regarding any appintment reminders, insurance items, and any matters pertaining t my clinical care, including test results, etc. (Please list n the line belw the name f family members r ther persn(s) with whm we may speak. Shuld yu wish we nly speak t yu regarding yur PHI, please state Patient nly ) Mail t my hme address any items that may assist the practice in carrying ut treatment, payment, and health care peratins. Send electrnic medicatin prescriptins t my pharmacy, and when available btain medicatin histry recrds t be dwnladed int my electrnic medical recrd. I may revke my cnsent in writing except t the extent that the practice has already made disclsures in reliance upn my prir cnsent. If I d nt sign this cnsent, r if I later revke it, Baratta Dermatlgy may decline t prvide treatment t me. Signature f Patient r Legal Guardian Print Patient s Name Patient s Date f Birth Print Name f Patient s Legal Guardian, if applicable Date (The Patient/Legal Guardian may request a phtcpy f this signed cnsent) Versin: Rt. 38 Suite 8 Hainesprt NJ P: F: inf@barattadermatlgy.cm

4 Bipsy Cnsent During yur visit, yu may require a bipsy. Please read and sign belw t allw yur physician t take a bipsy sample if necessary during yur visit. Ratinale A skin bipsy allws the dermatlgist t test a lesin r rash under the micrscpe t btain a diagnsis. It usually invlves numbing the area with numbing medicatin, remving a small piece f skin. Wund care instructins will be prvided t yu at the end f yur visit. Risks and Cmplicatins Specific t Skin Bipsies/Excisins Bleeding Infectin Pain Scar Incmplete Remval Recurrence Nerve Damage/Numbness Allergic reactin t anesthesia The physician has explained t the patient/family/guardian the nature f the patient's cnditin, the nature f the prcedure, and the benefits t be reasnably expected cmpared with alternative appraches. The physician has discussed the likelihd f majr risks r cmplicatins f this prcedure including the specific risks listed abve and (if applicable) drug reactins, hemrrhage, infectin, cmplicatins frm bld r bld cmpnents. The physician has als indicated that with any prcedure there is always the pssibility f an unexpected cmplicatin. Signature: Date: Versin: Rt. 38 Suite 8 Hainesprt NJ P: F: inf@barattadermatlgy.cm

5 APPOINTMENT CANCELLATION/NO SHOW POLICY Thank yu fr trusting yur medical care t Baratta Dermatlgy. When yu schedule an appintment with Baratta Dermatlgy we set aside enugh time t prvide yu with the highest quality care. Shuld yu need t cancel r rescheduled an appintment please cntact ur ffice as sn as pssible, and n later than 24 hurs prir t yur scheduled appintment. This gives us time t schedule ther patients wh may be waiting fr an appintment. Please see ur Appintment Cancellatin/N Shw Plicy belw: An established patient wh fails t shw r cancels/reschedules an appintment and has nt cntacted ur ffice with at least 24 hurs ntice will be cnsidered a N Shw and charged a $25.00 fee. Any established patient wh fails t shw r cancels/reschedules an appintment with n 24 hur ntice a secnd time will be charged a $50.00 fee. If a third N Shw r cancellatin/reschedule with n 24 hur ntice shuld ccur the patient may be dismissed frm Baratta Dermatlgy. Any new patient wh fails t shw fr their initial visit will be able t reschedule the visit withut a fee, if the patient fails t shw fr their secnd time, a $50 fee will be charged. The fee is charged t the patient, nt the insurance cmpany, and is due at the time f the patient s next ffice visit. As a curtesy, when time allws, we make reminder calls fr appintments. If yu d nt receive a reminder call r message, the abve plicy will remain in effect. We understand there may be times when an unfreseen emergency ccurs and yu may nt be able t keep yur scheduled appintment. If yu shuld experience extenuating circumstances please cntact ur frnt desk staff wh may be able t waive the N Shw fee. Yu may cntact Baratta Dermatlgy 24 hurs a day, 7 days a week at Shuld it be after regular business hurs Mnday thrugh Friday, r a weekend, yu may leave a message. I have read and understand the Medical Appintment Cancellatin/N Shw Plicy and agree t its terms. Signature (Parent/Legal Guardian) Date Versin: Rt. 38 Suite 8 Hainesprt NJ P: F: inf@barattadermatlgy.cm

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