M.D. APPOINTMENT DATE: TIME: FLOOR: 2 MOHS SURGERY
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1 Dermatology & Allergy Specialists of Olympia, PLLC Mohs Dept: 304 West Bay Dr NW, Suite 204, Olympia, WA Voice: (360) Fax: (360) Jacob Bauer, M.D. APPOINTMENT DATE: TIME: FLOOR: 2 MOHS SURGERY Thank you for choosing our Dermatology office! We look forward to making your visit as comfortable and productive as possible. The following steps will help us provide the best use of your time with the provider: Minor Patients: All minors must be accompanied by a parent/legal guardian at each visit. If not accompanied by parent/legal guardian the appointment may be rescheduled. Please arrive 15 minutes early so we can register/update your information. Please provide ALL insurance cards, Picture ID, POA and/or current ProviderOne card if applicable: Current insurance card/s are required by your insurance company to be presented at every visit to our office. Your appointment will be rescheduled to the next available appointment if you do not present all insurance cards at registration. Your insurance company obligates us to maintain a copy of your insurance card in your medical record for the purpose of billing your visit. Please refrain from wearing perfume or colognes to our office. Many of our patients have severe allergies, and as a courtesy to them our office is a "scent free" zone. Bring your referral, if required. Your insurance company can tell you if you need a referral; we are unable to contact them for you. If your insurance company requires a referral and one is not provided to us, your appointment will be rescheduled. Please be prepared to pay your co-pay at the time of check-in if one is required. We charge a $5.00 fee to bill you later for co-pays. Please bring in the containers of any medications or over-the-counter products that you are using to treat the current problem. Please read entire packet and completely fill out any forms sent to you before arrival. Individuals seeking treatment are not considered to have been accepted into the practice and formed a provider-patient relationship until they have completed a faceto-face visit with a provider who has completed an evaluation and assessment. We recommend you allow plenty of time for your first appointment. This initial visit takes time to register, and we do not want to shorten your time with the provider or have to reschedule your appointment if you are late. Due to the shortage of dermatology providers, your appointment may have been scheduled some time ago, and it may not work with your current schedule. Please call us as soon as you are aware that you need to reschedule. With 24 hours notice, we are happy to reschedule; however the new time might be several weeks later. If you fail to keep your appointment without notifying us in advance, you will not be rescheduled again. For your convenience, our appointment line is available to take a message 24 hours a day. Please call (360) if you wish to leave a message. You may call us during office hours of 8 a.m. to 5 p.m. Monday through Thursday, or 8 a.m. to 4 p.m. Friday, to reach a receptionist. DIRECTIONS: Please see reverse side.
2 Directions to Dermatology & Allergy Specialists of Olympia TRAVELING SOUTH on I-5, EXIT 105B: Head west off Exit 105B, down ramp and travel 0.3 mi. Merge onto Plum St SE. Follow Plum St. to State Avenue, approximately 0.6 mi. Turn left onto State Ave NE and go 0.6 mi. Stay to the right and merge onto 4th Ave W and cross the bridge. At the first traffic circle, stay to the right and follow Olympic Way to the second traffic circle. Stay to the right and take the 1st exit on the right: West Bay Drive NW. The office will be one block down on the right. TRAVELING NORTH on I-5, EXIT 103: Head down the ramp to Deschutes Way SE and remain on this road as it becomes Deschutes Parkway SW. Continue on Deschutes Pkwy SW along the west side of Capital Lake for 1.8mi. Deschutes Pkwy turns into 5 th Ave at the junction with the bridge. Travel for 0.1mi. Turn left on Simmons Street NW. Turn left onto 4th Ave W and cross the bridge. Merge into right lane and at the first traffic circle, stay to the right and follow Olympic Way to the second traffic circle. In the right lane take the 1st exit on the right: West Bay Drive NW. The office will be one block down on the right. TRAVELING EAST on Highway 101: Take the Black Lake Blvd exit toward W Olympia. At bottom of ramp turn left onto Black Lake Blvd SW, Travel 1.2mi. Turn right onto Harrison Ave NW and go approximately 0.6mi. As you head downhill, stay in left lane as you enter the traffic circle. Proceed around to the left, merge to the right and take the 2nd exit (right) onto W Bay Drive NW. The office will be one block down on the right. J. Mark Bauer, M.D. Jacob H Bauer, M.D. Shauna M. Richert, M.D. Michael K. Elm, M.D. Sukanya Kanthawatana, M.D., Ph.D. Sarra Vashchenko, PA-C Jennifer Winter, PA-C
3 Dermatology & Allergy Specialists Of Olympia 304 West Bay Dr. NW, Olympia, WA 98502; General Dermatology, Ste 301; Mohs, Ste 204 Date: Patient Information Last Name: First Name: _ Middle Initial Marital Status: Single / Married / Divorced / Widowed Sex: Date of Birth: Mailing Address: City: State: Zip: Physical Address: City: State: Zip: Primary Phone#: Secondary Phone#: Emergency Contact: Relation: Phone #: Employer: Work Phone #: SS#: Spouse/Guarantor/Self (Please Circle) Last Name: First Name: Middle Initial Sex: Date of Birth: Mailing Address: City: State: Zip: Contact Phone #: Employer: Work Phone#: SS#: Insurance Information (PLEASE PRESENT INSURANCE CARDS AND NECESSARY REFERRALS TO THE RECEPTIONIST SO COPIES MAY BE MADE) Primary Insurance: Insurance Phone #: Ins Address: Policy#: Group#: Subscriber: Subscriber s Birthdate: Relation to Patient: Same / Spouse / Child / Other (Please Circle) Subscriber s Employer: Secondary Insurance: Insurance Phone #: Ins Address: Policy#: Group#: Subscriber: Subscriber s Birthdate: Relation to Patient: Same / Spouse / Child / Other (Please Circle) Subscriber s Employer:
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5 Dermatology and Allergy Specialists of Olympia, PLLC 304 West Bay Dr NW Olympia, WA General Dermatology, STE 301; Mohs Surgery, STE 204 Welcome to our practice! Please take the time to fill out the Health History Questionnaire below prior to your visit, as this will help speed the initial aspects of your visit with us. Patient Name: DOB: Primary MD: Pharmacy: Past Medical History: (Please add dates) Past Surgeries: (Please add dates) Anxiety Arthritis: Type Asthma Atrial Fibrillation / Irregular heartbeat BPH (prostate) Bone Marrow Transplant Breast Cancer Colon Cancer COPD Coronary Artery Disease Depression Diabetes End Stage Renal Disease Fibromyalgia Gastroesophageal Reflux Other Hearing Loss Hepatitis: A B or C Hypertension HIV / AIDS Hypercholesterolemia Hyperthyroidism Leukemia Lung Cancer Lymphoma Prostate Cancer Radiation Treatment Seizures Stroke Please circle all that apply. Appendix (appendectomy) Bladder (Cystectomy) Breast: Mastectomy R L B Breast: Lumpectomy R L B Breast: Biopsy R L B C Section Colon (colectomy for cancer) Colon (colectomy for diverticulitis) Gallbladder (cholecystectomy) Heart: PTCA Heart: Mechanical Valve replacement Heart: Biological Valve replacement Heart: Transplant Uterus: Hysterectomy Joint replacement: Knee R L B Other: Joint replacement: Hip Kidney biopsy Kidney removal (nephrectomy) Kidney stone removal Kidney transplant: Year Ovaries: Endometriosis Ovaries (Ovarian cancer) Prostate removal (cancer) Prostate: biopsy Prostate (TURP procedure) Skin Surgery Biopsy Basal cell carcinoma Squamous cell carcinoma Melanoma Other: Spleen (splenectomy) Testicles (orchidectomy) Tonsillectomy Dermatology History: Acne Actinic Keratoses (pre-cancers) Asthma Basal cell skin cancer** Blistering sunburns Dry skin Eczema Other: Flaking or itchy scalp Hay Fever / Allergies Melanoma** Poison Ivy Precancerous or atypical moles Psoriasis Rosacea Squamous cell skin cancer** ** If yes, please list cancer, location, date, and treatment Page 1 Staff Initials / Date Please fill out other side
6 Patient Name: DOB: Do you wear Sunscreen? No Yes (SPF ) Tanning salon? No Yes Past Family history of skin cancer? No Yes Type: BASAL CELL SQUAMOUS CELL MELANOMA UNKNOWN (circle one) If yes, (circle) mother father sister brother daughter son uncle aunt nephew grandmother grandfather grandson granddaughter Other Please list any medications and supplements or vitamins that you are taking: Are you allergic to latex? Yes No Reaction: Please list any allergies to medicines or anesthesia that you may have and the reaction: Social History: Do you use illicit, intravenous or recreational drugs? Yes Type: No Do you drink alcohol? No Yes (circle one) Less than 1 drink/day; 1-2 drinks/day; 3 or more drinks/day Do you feel safe at home? Yes No Marital status? Single Married Divorced Widowed Partner Occupation (s):_ Hobbies / Leisure activities: Where did you grow up and/or spend significant time in your life? Do you or have you ever smoked? How often do you exercise? Current everyday smoker: packs per day Occasional smoker Former smoker year quit Never smoker Several times a day Once a day A few times a week or month Never What is your caffeine use? Several times a day Once a day A few times a week or month Never (Women) Are you pregnant? Yes No Are you planning? If yes, due date? Page 2 Staff Initials/Date
7 Dermatology & Allergy Specialists of Olympia Main Office: 304 West Bay Dr NW, Suite 301, Olympia, WA Voice:(360) Fax: (360) Allergy Office: 703 Lilly Road NE, Suite 103, Olympia, WA Voice: (360) Fax: (360) Notice of Privacy Practices Acknowledgement Due to the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule, we must have your written acknowledgement of having had an opportunity to receive and review a copy of our Notice of Privacy Practices. I, acknowledge the opportunity to review and receive (PRINT PATIENT NAME HERE) Dermatology and Allergy Specialists of Olympia, PLLC. Notice of Privacy Practices. OFFICE USE ONLY: Patient refuses, or is unable to acknowledge receipt of the Notice of Privacy Practices. Employee Signature Date Disclosures to Family and Friends and Clinical Information Calls Under normal circumstances we would share some of your private health information (PHI) with some of your family members. Please read and complete both of the following: 1. I agree that this office may disclose my private health information to only the following individuals that are my family members or friends (PLEASE PRINT) NAME: PHONE NUMBER: RELATIONSHIP: ALL INFORMATION FOR EMERGENCY ONLY NAME: PHONE NUMBER: RELATIONSHIP: ALL INFORMATION FOR EMERGENCY ONLY OR: I do not want my private health information disclosed to any individual asking about me, regardless of whether or not they may be a family member or friend. 2. How would you like us to communicate with you regarding clinical information (such as test results and treatment plans)? Following your visit may we call and leave a message on the following: Home Phone ( ) Cell phone ( ) Work Phone ( ) Other ( ) Signature Date Relationship to patient if signed on behalf of the patient J. Mark Bauer, MD Jacob H. Bauer, MD Linda L. Brown, MD Michael K. Elm, MD Sukanya Kanthawatana, MD, PhD Shauna M. Richert, MD Samantha Ferguson, PA-C Sarra Vashchenko, PA-C Jennifer Winter, PA-C
NAME MEDICAL HISTORY DATE Past Medical History: (Please circle all that apply): NONE Anxiety Coronary Artery Disease HIV/AIDS Seizures Arthritis Depre
GENERAL INFORMATION Patient Name Preferred Name of Birth / / Age Sex Height Weight Address Street City State Zip Home Phone Cell Phone Work Phone Social Security Number Email Emergency Contact: Name &
MRN: (Office Use Only) Patient Information. Legal Name: (Last) Mr. Mrs. Ms. (First) (Middle)
Patient Information MRN: (407) 260-2606 Fax (407) 260-6339 Date: Patient Information Legal Name: (Last) Mr. Mrs. Ms. (First) (Middle) Mailing Address: (Street) (City) (State) (ZIP) Phone: ( ) ( ) ( ) (Home)
WILLIAM SAWCHUCK, M.D. GAYLE MASRI-FRIDLING, M.D OLD COURTHOUSE ROAD, SUITE 303 VIENNA, VA TELEPHONE: (703) FAX: (703)
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PATIENT REGISTRATION FORM
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Patients Name: (Last, First, MI): SSN: DOB: Circle One: Male Mailing Address: Apt. #: City: State: Zip Code: Female Race: Ethnicity Primary Language: Home Phone: Preferred? Cell Phone: Preferred? Employer:
Page 1 of 5 1/4/17. Print Guardian Name (If not patient) DOB: Circle One: - - Patients Name: (Last, First, MI):
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R. B. KO L A C H A L A M M. D. GENERAL SURGERY
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716 S. Goldenrod Road n 3315 Orange Blossom Trail Fax (407) 658-2536 Fax (407) 343-1907 ADULT PATIENT INFORMATION Patient Name: Last Name First Name MI Address: City: State: Zip Code: Phone #: Cell Phone
Please allow us hours to refill the medication; approval from your medical provider is required on all refills.
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HouseCalls-MD 2998 W. Montague Ave. Suite 117 N. Charleston, SC 29418 Info@housecalls-md.com Office 843-501-2031 www.housecalls-md.com Fax 888-453-0810 Patient Information: Last Name First Name MI Gender
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5056 THOROUGHBRED LANE BRENTWOOD, TN 37027 TODAY S DATE: PHONE: 615-373-3337 FAX: 615-373-3782 PATIENT S NAME: DATE OF BIRTH: M F RESPONSIBLE PARTY/GUARANTOR INFORMATION LAST NAME: FIRST NAME: MI: DOB:
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Patient Name Today s Date: Mailing Address Home Phone: City State Zip: Work Phone: Cell Phone: Birth Date: / / Age: SSN: Sex: Male Female
Patient Registration Patient Name Today s Date: Mailing Address Home Phone: City State Zip: Work Phone: Email: Cell Phone: Birth Date: / / Age: SSN: Sex: Male Female Marital Status: Single Married Widowed
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Christopher I. Zoumalan, M.D., Inc. Aesthetic and Reconstructive Oculoplastic Surgery 9401 Wilshire Blvd. Suite 1105 Beverly Hills, CA.
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908 South 10 th Street Office: 337.392.2330 Fax: 337.392.2580 West State Orthopedics and Sports Medicine Clinic, LLC Patient Registration Form Date: / / Patient Name: Birth Date: / / (last) (first) (mi)