New Patient Form

Name(Required)

First MI Last

Birthdate(Required)

Sex(Required)

Male

Female

Marital Status(Required)

Single

Married

Divorced

Widowed

Spouses Name(Required)

First MI Last

Address(Required)

Street Address Address Line 2 City State Zip Code

Home Phone

Mobile Phone

Email(Required)

(By providing an Email address, I authorize your office to contact me via the email address provided)

Occupation

Employer

Employer Phone

Primary Care Physician

Referred By

Smoking Status:(Required)

Never been a smoker

Current, sometimes smoker

Current, every day smoker

Previous smoker

Caffeine Usage:(Required)

Once a day

Several times a week

Several times a month

Never

Exercise:(Required)

Once a day

Several times a week

Several times a month

Never

Sunscreen Usage(Required)

Yes

SPF

Tanning Salon Usage(Required)

Yes

Ethnicity(Required)

Hispanic or Latino

Not Hispanic or Latino

I choose not to specify

**This question is included to comply with new Federal Health guidelines - we are required to ask for this information

Race(Required)

American Indian/Alaskan Native

Asian

Black/African American

Native Hawaiian/Other Pacific Island

White

I choose not to specify

Other

**This question is included to comply with new Federal Health guidelines - we are required to ask for this information

Preferred Language(Required)

English

Spanish

American Sign Language

I choose not to specify

Other

**This question is included to comply with new Federal Health guidelines - we are required to ask for this information

Insurance / Guarantor Information

Do you have health insurance?(Required)

Yes

If you're not using medical insurance, we do accept self pay patients as well.

Primary Insurance(Required)

Subscriber #(Required)

Responsible Party(Required)

Responsible Party Name(Required)

Birthdate of Responsible Party(Required)

Do you have Secondary health insurance?

Yes

Secondary Insurance(Required)

Secondary Insurance Subscriber #(Required)

Secondary Insurance Responsible Party(Required)

Secondary Insurance Responsible Name(Required)

Birthdate of Responsible Party of Secondary Insurance(Required)

Emergency Contact

Name(Required)

Phone Number(Required)

Relationship to Patient(Required)

24 Hour Cancellation & "No Show" Fee Policy

Each time a patient misses an appointment without providing proper notice, another patient is prevented from receiving care. Therefore, Skin Health Forever Dermatology reserves the right to charge a fee of $25.00 for all missed appointments (“no shows”) and appointments which, absent of a compelling reason, are not cancelled with a 24-hour advance notice. “No show” fees will be billed to the patient. This fee is not covered by insurance, and must be paid prior to your next appointment. Thank you for your understanding and cooperation as we strive to best serve the needs of all of our patients. By signing below, you acknowledge that you have received this notice and understand this policy.

Authorization(Required)

I hereby authorize Thomas M. Taylor MD to render treatment to me. I hereby Authorize Payment of medical benefits to Thomas M. Taylor MD. I hereby agree to pay any fee incurred in the course of my treatment; as such services are rendered to Thomas M. Taylor MD. I hereby authorize any physician or hospital to release records to Thomas M. Taylor MD. I hereby authorize Thomas M. Taylor MD to release medical records to any physician or hospital upon written request for such information.

Date(Required)

Name(Required)

First Last

History and Intake

Past Medical History

Please Check All That Apply

Other Past Medical History

Past Surgical History

Please Check All That Apply

Was your Mastectomy Right, Left or Bilateral?(Required)

Left

Right

Bilateral

Was your Lumpectomy Right, Left or Bilateral?(Required)

Left

Right

Bilateral

Was your Breast Biopsy on your Right, Left or Bilateral?(Required)

Left

Right

Bilateral

Was your Knee Replacement Right, Left or Bilateral?(Required)

Left

Right

Bilateral

Was your Hip Replacement Right, Left or Bilateral?(Required)

Left

Right

Bilateral

Was your Kidney Removal Right, Left or Bilateral?(Required)

Left

Right

Bilateral

Was your Testicle Removal Right, Left or Bilateral?(Required)

Left

Right

Bilateral

Other Past Surgical History

Skin Disease History

Please Check All That Apply

Other Skin Disease History

Do you have a family history of Melanoma?(Required)

Yes

Which Relative(s)?

Any other family history:

Medications

Please enter all current medications

Allergies

Please enter all allergies

Pharmacy Information

Name of Pharmacy(Required)

Phone Number:(Required)

Address

Street Address Address Line 2 City State ZIP Code

Payment for Medical Services

Most of our patients have health insurance coverage. Some of our patients have such coverage through health maintenance organizations. Regardless of any health insurance coverage, a patient receiving health care services is financially responsible for any health care services that are not covered by insurance.

With respect to any health care services that are not covered by your health insurance policy, payment is due at the time the services are rendered. Co-payments and deductibles are payable at the time health care services are rendered. As a courtesy, our office files insurance claims on behalf of our patients; however, the responsibility of paying our office for any health care services that are not covered by your health insurance is your responsibility. If for some reason you are unable to pay in full for any health care services, you should contact our billing department to make payment arrangements.

If you do not pay us for health care services in a timely manner, we reserve the right to charge interest at the rate of six percent (6%) per annum on any unpaid balance. Our office may turn over any unpaid balance for collection. We accept cash, personal checks, MasterCard, Visa, American Express, and Discover. If we receive a worthless check, our office will charge the maximum service charge permitted by law and our office may file a collection action with respect to the worthless check.

Name of Insurance Company(Required)

Signature of Patient(Required)

Printed Name(Required)

Date(Required)

Notice of Privacy Policies

*THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN ACCESS TO THIS INFORMATION.

Allowed uses and disclosures of your medical information:
1. Thomas M. Taylor MD, PA may use or disclose protected health information for the purposes of treatment, payment, or healthcare operations, for example communications with healthcare providers and submission of health insurance claims.
2. Thomas M. Taylor MD, PA may use or disclose personal health information for the following reasons:
  1. Use and disclosure for public health activities
  2. Reporting about victims of abuse, neglect, or domestic violence
  3. Disclosures for law enforcement purposes
  4. Disclosure for judicial and administrative proceeding
  5. Disclosure to avert a serious threat to health or safety
Additional uses disclosures:
1. Thomas M. Taylor MD, PA may contact the patient to provide appointment reminders or information about treatment alternatives or other health related benefits and services that may be of interest to the patient.
You have the right to:
1. Request restrictions on certain uses and disclosures, however, we are not required to agree to any requested restriction
2. Receive confidential communications from us upon written request
3. Inspect and request copies of your medical information
4. Receive an accounting of any disclosures made, upon written request
5. Receive a paper copy of the notice upon request
We are responsible for:
1. Maintaining the privacy of your medical information
2. Providing this notice
3. Abiding by the terms of this notice
4. Providing written notice of any changes to this notice
Complaints: You may complain to us or to the Health and Human Services Secretary if you believe that your privacy has been violated. If you wish to file a complaint with us, please provide the office manager with a written notice of how you believe we violated your privacy. All notices received will be investigated and reviewed by a physician. We will respond within two weeks, and we will not retaliate for any allegations made.
Authorization: Upon your authorization, we may disclose your complete medical information, including pathology and billing information, to a requesting entity, such as an attorney, another provider, or a relative. Unless otherwise specified, we reserve the right to release as much information as we feel necessary pertaining to the request. You may revoke any authorization you make at any time, except to the extent that it was already relied on.

Signature of Patient(Required)

Printed Name(Required)

Date(Required)

Phone

This field is for validation purposes and should be left unchanged.

Cosmetic & Aesthetic

General Dermatology

Conditions We Treat

South Tampa Office

Brandon Office

New Patient Form

Insurance / Guarantor Information

Emergency Contact

24 Hour Cancellation & "No Show" Fee Policy

History and Intake

Pharmacy Information

Payment for Medical Services

Notice of Privacy Policies

Contact Us

Brandon Office

Quick Links

Conditions

Medical Services

Aesthetic Services