THE PATIENT INFORMATION FORM IS PART OF YOUR RECORD AND MUST BE COMPLETED IN ITS ENTIRETY


*Items in BOLD are required

SECTION I: PATIENT INFORMATION

Today's Date: //

Patient Last Name: First Name: Middle:

Date of Birth: // Age: Social Security Number:--

Sex: F     Marital Status: Single  Married  Divorced  Widow


Referred By:

Patient Home Address:



Home Phone: ()-   This is my preferred contact number
Cell Phone:    ()-   This is my preferred contact number
Work Phone:  ()-   This is my preferred contact number

Email:
Occupation:
Employer Name:
Work Address:

Primary Care Physician:
Phone:()- Address:

Pharmacy Name:
Pharmacy Phone Number:()-


Emergency Contact:
Relationship: Phone Number:()-

IS THE PATIENT A MINOR? Y   N
 
IF THE PATIENT IS A MINOR - FINANCIAL INFORMATION

Person Responsible For Payment:
Relationship To Patient:
Social Security Number:-- Date of Birth://
Home Address:



Home Phone:()-   Work Phone:()-
Employer Name:
Work Address:

CONSENT FOR PHOTOGRAPHY
I hereby give my permission to my physician or any assistant that she may designate to take photographs for diagnostic purposes and to enhance the medical record.  I agree that these photographs will remain in her property and she may use them for medical, scientific or other presentations and publications.
Patient Name: Date://
Signature:


SECTION II: MEDICAL HISTORY


MEDICAL HISTORY:   (CHECK ALL THAT APPLY)
Y N  DUODENAL OR PEPTIC ULCER
Y N  OTHER INTESTINAL DISEASE OR COLITIS
Y N  LIVER OR GALLBLADDER DISEASE
Y N  HEART DISEASE (RHEUMATIC FEVER, PACEMAKER, OTHER)
Y N  HIGH BLOOD PRESSURE
Y N  STROKE
Y N  KIDNEY DISEASE
Y N  ENDOCRINE DISORDER
Y N  URINARY OR BLADDER PROBLEM OR INFECTION
Y N  HEPATITIS A, B, OR C
Y N  HIV
Y N  HERPES SIMPLEX
Y N  VENEREAL DISEASE
Y N  BLOOD OR LYMPH GLAND DISORDER
Y N  EYE DISEASE (GLAUCOMA, CATARACT, OTHER)
Y N  THROMBOPHLEBITIS
Y N  CANCER
Y N  FREQUENT INFECTIONS (SKIN OR OTHER)
Y N  NEUROLOGICAL DISORDER
Y N  EMOTIONAL OR PSYCHIATRIC PROBLEM
Y N  EXCESSIVE BLEEDING WHEN CUT
Y N  DIFFICULTY WITH THE HEALING OF WOUNDS
Y N  OVERGROWN SCARS OR KELOIDS
Y N  ALLERGY TO LOCAL ANESTHETICS
Y N  ARE YOU PREGNANT?
Y N  ARE YOU CURRENTLY PLANNING A PREGNANCY?

PLEASE LIST ANY MEDICAL CONDITIONS NOT LISTED ABOVE:


HAVE YOU PREVIOUSLY HAD A SKIN PROBLEM OR BEEN UNDER THE CARE OF A  DERMATOLOGIST?  
NO YES
DO YOU TAKE ANY MEDICINES, DRUGS, OVER-THE-COUNTER PREPARATIONS, VITAMINS OR HERBAL REMEDIES?  
NO YES
ARE YOU ALLERGIC TO ANY MEDICINES, DRUGS, LATEX, OVER-THE-COUNTER PREPARATIONS OR HERBAL REMEDIES?  
NO YES


PRIOR HOSPITALIZATIONS AND SURGERY (APROXIMATE DATES):


HAVE YOU OR ANY MEMBERS OF YOUR FAMILY (SPECIFY WHO) HAD:
Y N  AUTO-IMMUNE DISEASE
Y N  MELANOMA
Y N  ANY CANCER

PLEASE INFORM THE DOCTOR AT ANY TIME IF YOU PLAN TO OR BECOME PREGNANT.
 



SECTION III: SOCIAL HISTORY


DO YOU DRINK ALCOHOL? NO YES
IF YES,  DRINKS PER DAY

DO YOU USE RECREATIONAL DRUGS? NO YES
IF YES, WHICH ONES?
HOW MUCH?

DO YOU SMOKE? NO YES
IF YES, HOW MUCH?

THE DERMATOLOGICAL EXAMINATION WHICH YOU ARE ABOUT TO RECEIVE IS NOT A COMPLETE PHYSICAL EXAMINATION. IT IS SUGGESTED THAT YOU HAVE A COMPLETE PHYSICAL EXAMINATION PERIODICALLY BY YOUR FAMILY PHYSICIAN OR INTERNIST.

I certify that I have read and filled out the patient registration and medical history form fully and correctly to the best of my knowledge, and that the information that I have supplied is complete and correct. I understand that withholding medical information could lead to complications or problems that may have been prevented if that information were known prior to my care and treatment. I acknowledge that I can obtain and will read  information regarding the providers of care in this organization, DNR (Do Not Resuscitate), Patient’s Bill of Rights and Responsibilities, HIPAA regulations, and information regarding the grievance process.
Signature: DATE//
 

SECTION IV: OUR PRACTICE FINANCIAL POLICY


THE PRACTICE FINANCIAL POLICY WILL BE GIVEN TO PATIENTS AT THE TIME OF REGISTRATION. ALL PATIENTS MUST SIGN THIS FORM.
We are dedicated to providing you with the best possible care and service. To assist you, we have the following financial policies.  If you have any questions, please feel free to discuss them with our staff.

PAYMENT IS EXPECTED AT THE TIME OF TREATMENT.
We will provide you with a form to present to your insurance carrier (if applicable). We accept cash, personal checks, and credit cards (American Express, Mastercard, and Visa.)

MINOR PATIENTS
For all services rendered to minor patients, the adult accompanying the patient is responsible for payment.

PATHOLOGY AND LABORATORY FEES
Pathology and laboratory fees are separate from our fees and will be billed directly to you. You will receive a separate bill from the lab company.

CANCELLATION POLICY
Please note that appointments canceled within 24 hours of the appointment are subject to a $50 fee.
I have read, understand, and agree to the financial policies of this office. I am fully responsible for all professional fees and services rendered.

Parent/Guardian DATE//
Signature:  

SECTION V: PATIENT CONSENT FORM -- USE AND DISCLOSURE OF HEALTH INFORMATION PROTECTED UNDER HIPAA


Pursuant to the information contained in the Notice of Privacy Practices, I give permission for the use and disclosure of Protected Health Information (PHI) in order to carry out Treatment, Payment, and Healthcare Operations (TPO).

I am aware that I have the right to review the Notice of Privacy Practices prior to signing this consent.  Should the Notice of Privacy Practices be revised, I am aware that I may obtain a copy of the revised form by contacting the Medical Director of this facility.

I give my consent for this organization to contact me by calling my home or other designated location in order to leave a message (mechanically or with another person) or to speak to me directly regarding any matter which will help with the conduct of Treatment, Payment, and Healthcare Operations.

Further, I give my consent for the use of mail or e-mail to designated locations, including my home, to assist the organization in carrying out the described activities of Treatment, Payment, and Healthcare Operations.

I hereby consent to the use and disclosure of my PHI for the purpose of Treatment, Payment, and Healthcare Operations (TPO). This consent is good until revoked in writing, except to the extent those disclosures have been made in reliance upon my prior consent.

Services are provided without regard to sex, race, color, religion, national origin, or disability.
 
Patient name DATE//
Patient Signature

If applicable, Legal Guardian Name:
Legal Guardian Signature .
 

SECTION VI: LEARNING ASSESSMENT


During your visit with our organization you will be presented with information that may be new to you.  To aid in providing the best care possible please answer the following questions.  

How do you like to learn new things?  Please check all that apply:
Brochures  Reading  Hands-On/Demonstration  Discussion

Do you speak English in your home? Yes  No
If no, what language do you speak?
Name of interpreter:

Can you read English? Yes  No

Can you write English? Yes  No

Do you hear well? Yes  No
If no, do you utilize a hearing device? Yes  No

Do you see well? Yes  No
If no, do you utilize glasses or contacts? Yes  No

Do you have any cultural or religious practice/beliefs that may affect your care or treatment? Yes  No
If yes, please explain

  

SECTION VII: UNIVERSAL MEDICATION FORM


Name
Birth date
Address:

Phone Number
Email
Allergies

LIST ALL MEDICINES YOU ARE CURRENTLY TAKING: 1) Prescription and over-the-counter medications (examples: aspirin, antacids); herbals (examples: ginseng, gingko); and vitamins. Include medications taken as needed (example: nitroglycerin).  Please also include if you received any injections recently, i.e. steroids.  2) CROSS OFF any medications you no longer take.  3) Keep this card in chart at all times.  Show this card to every doctor visit on every visit, every visit to an emergency room and on admission to any hospital.  4) NEVER take drugs prescribed for someone else.

  MEDICATION #1:
Date Prescribed:
Medication/Dose:
Directions (How many times per day you take and when):
Medication held due to procedure? YES  NO
Date Stopped:
Notes: Reason for taking/Doctor name:

MEDICATION #2:
Date Prescribed:
Medication/Dose:
Directions (How many times per day you take and when):
Medication held due to procedure? YES  NO
Date Stopped:
Notes: Reason for taking/Doctor name:

MEDICATION #3:
Date Prescribed:
Medication/Dose:
Directions (How many times per day you take and when):
Medication held due to procedure? YES  NO
Date Stopped:
Notes: Reason for taking/Doctor name:

MEDICATION #4:
Date Prescribed:
Medication/Dose:
Directions (How many times per day you take and when):
Medication held due to procedure? YES  NO
Date Stopped:
Notes: Reason for taking/Doctor name:

MEDICATION #5:
Date Prescribed:
Medication/Dose:
Directions (How many times per day you take and when):
Medication held due to procedure? YES  NO
Date Stopped:
Notes: Reason for taking/Doctor name:

MEDICATION #6:
Date Prescribed:
Medication/Dose:
Directions (How many times per day you take and when):
Medication held due to procedure? YES  NO
Date Stopped:
Notes: Reason for taking/Doctor name:

MEDICATION #7:
Date Prescribed:
Medication/Dose:
Directions (How many times per day you take and when):
Medication held due to procedure? YES  NO
Date Stopped:
Notes: Reason for taking/Doctor name:

MEDICATION #8:
Date Prescribed:
Medication/Dose:
Directions (How many times per day you take and when):
Medication held due to procedure? YES  NO
Date Stopped:
Notes: Reason for taking/Doctor name:

MEDICATION #9:
Date Prescribed:
Medication/Dose:
Directions (How many times per day you take and when):
Medication held due to procedure? YES  NO
Date Stopped:
Notes: Reason for taking/Doctor name:

MEDICATION #10:
Date Prescribed:
Medication/Dose:
Directions (How many times per day you take and when):
Medication held due to procedure? YES  NO
Date Stopped:
Notes: Reason for taking/Doctor name:

MEDICATION #11:
Date Prescribed:
Medication/Dose:
Directions (How many times per day you take and when):
Medication held due to procedure? YES  NO
Date Stopped:
Notes: Reason for taking/Doctor name:

MEDICATION #12:
Date Prescribed:
Medication/Dose:
Directions (How many times per day you take and when):
Medication held due to procedure? YES  NO
Date Stopped:
Notes: Reason for taking/Doctor name:

Patient Signature (if applicable): Date//

Responsible Adult Signature (if applicable): Date//
 

SECTION VIII: DISCLOSURE INFORMATION


Welcome to the practice, which is owned by Diane C. Madfes.

Your Surgeon/Physician: Dr. Diane C. Madfes is board certified by the American Board of Dermatology and is licensed in the State of New York, Connecticut and Florida. She has been in practice since 1996 and attended Brandeis University and Albert Einstein School of Medicine. She completed her internship in internal medicine at Yale University and her der-matology residency at Albert Einstein School of Medicine. You may request her C.V. which we keep on file. Her training is extensive in the field of dermatology surgery.

Your Surgeon/Physician: Dr. Esther L. Williams is board certified by the American Board of Dermatology and is licensed in the State of New York. She has been in practice since 2014 and attended Columbia University and Albert Einstein School of Medicine. She completed her internship in internal medicine at Staten Island University Hospital and her dermatology residency at Downstate Medical Center. You may request her C.V. which we keep on file. Her training is extensive in the field of dermatology surgery and skin cancer.

The Team: Our team is made up of competent individuals that will assist in providing safe patient care. All our medical assistants are all certified and play an important role in your care.

Should you have a problem: Please be advised that if you have a grievance or concern the following mechanism exists: Ask for the grievance form from the receptionist. Or you may call the accrediting organization that oversees our compli-ance with standards of care: The Joint Commission on Accreditation of Healthcare Organizations at (800) 994- 6610 or emailing complaint@jointcommission.org.

Make a suggestion: If you have a suggestion, please place this in writing and hand it to the receptionist or mail it.

Play a part in your care: We encourage all patients to be actively involved, so please speak up and ask questions.

DNR Policy: Please be advised that this organization does not recognize DO NOT RESUSCITATE orders or Living Wills.

If you have any questions, please see the receptionist.

Signature: Date://

Infection Control: We provide various in-services to our staff on Infection Prevention and Control issues annually. We monitor our organization for infections. This practice educates staff upon hire and annually in hand hygiene and we fol-low CDC guidelines for hand hygiene. We encourage staff to stay home when sick. We provide tissues and garbage cans throughout the facility and encourage everyone to cover mouths when coughing/ sneezing and wash their hands. Should you have a procedure in this organization, we want you to know that we value patient safety. Therefor you may hear us performing certain tasks or asking certain questions that may surprise you. Even though we may know you, we will ask you identifying information such as your date of birth or your address besides asking you to tell us your name. We take a pause or “time out” before we start your procedure. Only the physician performing your procedure will mark your surgical site. This organization adheres to strict infection control measures before, during, and after your procedure including but not limited to: procedural technique, environment of care, care of equipment and instruments, and education of all staff in the most up to date infection control measures.

JOINT COMMISSION ONLY: If anyone has concerns about patient care/ safety in the organization that we have not addressed, you’re encouraged to contact the organization’s management. If you feel the concerns were not resolved through the organization, you are encouraged to contact the Joint Commission by calling 800-994- 6610 or emailing complaint@jointcommission.org.

Signature: Date://
 

SECTION IX: REVIEW AND SUBMIT


Thank you for filling out our new patient form. Please take a moment to review your entries and make sure that the information is correct, and that all required fields are completed. If any required field is not completed, you will not be able to submit your paperwork.

SUBMIT THIS FORM: Please use the “SUBMIT” below. Your data will be encrypted and submitted via a HIPAA-compliant secure connection. You will receive a message after a successful submission.