PATIENT MEDICAL HISTORY Last Name First Name M.I. D.O.B / / Age Primary Care Physician and Lcatin: Pharmacy (name, city, and street): Email: 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) 1. 8. 2. 9. 3. 10. 4. 11. 5. 12. 6. 13. 7. 14. ALLERGIES (please list with reactins) 1. 3. 2. 4. 5. 6. 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: 06.2017 1299 Rt. 38 Suite 8 Hainesprt NJ 08036 P: 609.288.6884 F: 609.667.7103 inf@barattadermatlgy.cm www.barattadermatlgy.cm
Surgeries (please list year perfrmed) 1. 3. 2. 4. 5. 6. 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: 06.2017 1299 Rt. 38 Suite 8 Hainesprt NJ 08036 P: 609.288.6884 F: 609.667.7103 inf@barattadermatlgy.cm www.barattadermatlgy.cm
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: http://www.hhs.gv/cr/privacy 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, email, text, and/r leave messages n vice mail at the numbers and email 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: 06.2017 1299 Rt. 38 Suite 8 Hainesprt NJ 08036 P: 609.288.6884 F: 609.667.7103 inf@barattadermatlgy.cm www.barattadermatlgy.cm
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: 06.2017 1299 Rt. 38 Suite 8 Hainesprt NJ 08036 P: 609.288.6884 F: 609.667.7103 inf@barattadermatlgy.cm www.barattadermatlgy.cm
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 609-288-6884. 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: 06.2017 1299 Rt. 38 Suite 8 Hainesprt NJ 08036 P: 609.288.6884 F: 609.667.7103 inf@barattadermatlgy.cm www.barattadermatlgy.cm