New Patient Form Name(Required) First MI Last Birthdate(Required) MM slash DD slash YYYY 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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zip Code Home PhoneMobile PhoneEmail(Required) (By providing an Email address, I authorize your office to contact me via the email address provided)Occupation Employer Employer PhonePrimary 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 No SPF Tanning Salon Usage(Required) Yes No 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 informationRace(Required) American Indian/Alaskan Native Asian Black/African American Native Hawaiian/Other Pacific Island White I choose not to specify Other Other **This question is included to comply with new Federal Health guidelines - we are required to ask for this informationPreferred 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 informationInsurance / Guarantor InformationDo you have health insurance?(Required) Yes No If you're not using medical insurance, we do accept self pay patients as well.Primary Insurance(Required) Subscriber #(Required) Responsible Party(Required)SelfSpouseChildOtherResponsible Party Name(Required) Birthdate of Responsible Party(Required) MM slash DD slash YYYY Do you have Secondary health insurance? Yes No Secondary Insurance(Required) Secondary Insurance Subscriber #(Required) Secondary Insurance Responsible Party(Required)SelfSpouseChildOtherSecondary Insurance Responsible Name(Required) Birthdate of Responsible Party of Secondary Insurance(Required) MM slash DD slash YYYY Emergency ContactName(Required) Phone Number(Required)Relationship to Patient(Required) 24 Hour Cancellation & "No Show" Fee PolicyEach 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) MM slash DD slash YYYY Name(Required) First Last History and IntakePast Medical HistoryPlease Check All That Apply Anxiety Arthritis Artificial Joints Asthma Atrial Fibrillation BPH (Benign Prostatic Hyperplasia) Bone Marrow Transplantation Breast Cancer Colon Cancer COPD (Emphysema) Coronary Artery Disease Depression Diabetes End Stage Renal Disease GERD (Acid reflux) Hearing Loss Hepatitis Hypertension HIV/AIDS High Cholesterol Hyperthyroidism Hypothyroidism Leukemia Lung Cancer Lymphoma Pacemaker Prostate Cancer Radiation Treatment Seizures Stroke Valve Replacement None Other Past Medical History Past Surgical HistoryPlease Check All That Apply Appendix Removed Bladder Removed Mastectomy Lumpectomy Breast Biopsy Breast Reduction Breast Implants Colectomy: Colon Cancer Resection Colectomy: Diverticulitis Colectomy: IBD Gallbladder Removed Coronary Artery Bypass PTCA Mechanical Valve Replacement Biological Valve Replacement Heart Transplant Knee Replacement Hip Replacement Any Joint Replacement, within last 2 years Kidney Biopsy Kidney Removed Kidney Stone Removal Kidney Transplant Ovaries Removed: Endometriosis Ovaries Removed: Cyst Ovaries Removed: Ovarian Cancer Prostate Removed: Prostate Cancer Prostate Biopsy TURP Skin Biopsy Basal Cell Cancer Surgery Squamous Cell Carcinoma Surgery Melanoma Surgery Spleen Removed Testicles Removed Hysterectomy: Fibroids Hysterectomy: Uterine Cancer None 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 HistoryPlease Check All That Apply Acne Actinic Keratosis Asthma Basal Cell Skin Cancer Blistering Sunburns Dry Skin Eczema Flaking or Itchy Scalp Hey Fever/Allergies Melanoma Poison Ivy Precancerous Moles Psoriasis Squamous Cell Skin Cancer None Other Skin Disease History Do you have a family history of Melanoma?(Required) Yes No Which Relative(s)? Any other family history: MedicationsPlease enter all current medicationsAllergiesPlease enter all allergiesPharmacy InformationName of Pharmacy(Required) Phone Number:(Required)Address Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Payment for Medical ServicesMost 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.Consent(Required)I, the undersigned patient, acknowledge that I have read the foregoing statements and that I understand the foregoing statements. I further represent that I currently have health insurance coverage through the following insurance company: I agree to the Payment for Medical Services policyName of Insurance Company(Required) Signature of Patient(Required)Printed Name(Required) Date(Required) MM slash DD slash YYYY 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: 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. Thomas M. Taylor MD, PA may use or disclose personal health information for the following reasons: Use and disclosure for public health activities Reporting about victims of abuse, neglect, or domestic violence Disclosures for law enforcement purposes Disclosure for judicial and administrative proceeding Disclosure to avert a serious threat to health or safety Additional uses disclosures: 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: Request restrictions on certain uses and disclosures, however, we are not required to agree to any requested restriction Receive confidential communications from us upon written request Inspect and request copies of your medical information Receive an accounting of any disclosures made, upon written request Receive a paper copy of the notice upon request We are responsible for: Maintaining the privacy of your medical information Providing this notice Abiding by the terms of this notice 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) MM slash DD slash YYYY CommentsThis field is for validation purposes and should be left unchanged.