MD CLAIBORNE & ASSOCIATES LLC

NEW PATIENT INFORMATION FORM


Section I - Patient Information

First, Middle & Last Name: 
 
Address: 
 City: 
 State:
Zipcode:
    
 Personal Email: 
 Home Number: 
 Cell Phone Number: 
 SSN: 
 Date Of Birth: 
Gender: 
Marital Status: 
Race: 
 
 Employer: 
 Occupation: 
 Work Number: 
 Work Email: 
If referred, by whom: 
 
Preferred Physician: 
 
Primary Language: 

Please note that this office uses English as its primary language. We do not offer any interpreter or translation services. If you require an interpreter, you must provide one for yourself prior to medical treatment.

 

Section II - Minors

Parent/Guardian Name: 
Relationship To Patient:  
Are Addresss & Phone The Same?: 
 
If address for parent/guardian are not the same, please provide below: 
 
 City: 
 State:
Zipcode:
Home Number: 
 
Please note that children under the age of 18 must be accompanied by a parent or guardian at all visits.

Section III - Insurance


 
For medical record purposes, please present all current insurance cards to Front Desk for verification and scanning.
 
 Primary Policy Name: 
 Primary Policy Number: 
 Group Number: 
 Are you covered by more than one carrier?
 Picture/scan of the front and the back of your insurance card(s): 

Section IV - Authorizations

 
 Do you give permission for our office to discuss your medical information with family members? (if so please provide info below)
 
 Family Member 1 Name: 
 Family Member 1 Relationship: 
 Family Member 1 Phone: 
 Family Member 2 Name: 
 Family Member 2 Relationship: 
 Family Member 2 Phone: 
 
 Emergency Contact Name: 
 Contact Relationship: 
 Contact Home Number: 
 Contact Alternate Number: 
 
 May we leave personal medical information on your answering machine or cell phone? 
 
 How would you like to be addressed from the waiting room?
 
 How may this office contact you in regards to appointments, treatment, billing? (select all that apply)
 

Section V - Office Policy

 
 FINANCIAL -  

It is the policy of this office to collect all co-payments due at the time of the service. If a balance is due on your account, we will send you a statement for that balance. A total of only 2 statements will be sent. If no payment is received after the second notice, your account will be placed with an outside collection agency for settlement.
 

 APPOINTMENTS - 
 

This office is operated on an appointment only basis. We do not accept walk-ins. Your time is just as important as ours. If you are more than 15 minutes late for your scheduled appointment, we ask that you reschedule as a courtesy to others. If you need to cancel an appointment, please call as soon as possible to let us know. Patients who continually do not show for their scheduled appointments without calling to cancel will be asked to find care with another dermatologist. You will be sent a certified letter informing you of this decision.
 

 HIPAA - 
 We will protect your right to privacy as outlined by the HIPAA laws. Brochures are available throughout this office for your convenience. By signing below, you agree that you understand your rights under this policy.
 
 ASSIGNMENTS - 
 You agree to have all insurance payments sent directly to the doctor performing your service(s). We will file all charges as a courtesy for you to your carrier. There are times when medical information will be requested by your carrier in order to verify and process your charge(s). By signing below, you grant us the right to send this information on your behalf so that your charges may be settled.
 
 HIPAA - ASSIGNMENTS - 
 It is the policy of this office to collect all co-payments due at the time of the service. If a balance is due on your account, we will send you a statement for that balance. A total of only 2 statements will be sent. If no payment is received after the second notice, your account will be placed with an outside collection agency for settlement.
 
 TUMOR REGISTRY - 
 This office is mandated by law to record any malignant lesions with the Louisiana Tumor Registry. The information is protected under your HIPAA rights and is not forwarded to any other agency. By signing below you agree to allows us to record this information should it apply to you.
 


 
 Please type your full name to acknowledge that you understand and agree: 

 

MEDICAL HISTORY FORM


Medical History

Full Name: 
 Today's Date: 
 
Drug Allergies: 
 If you have drug allergies, please list them here: 
Your Pharmacy: 
 Pharmacy phone number: 
Name of primary doctor: 
 Primary doctor phone number: 
Do you currently take blood thinners? 
 

Current and Past Medical Condisitons and/or Diseases: (Please check all that apply)

 Diabetes: 
 Chronic Bronchitis: 
 Heart Murmur: 
 Asthma: 
 COPD: 
 Irregular Heartbeat: 
 Thyroid: 
 Shortness Of Breath: 
 Pacemaker: 
 Kidney: 
 High Blood Pressure: 
 Phlebitis: 
 Bladder: 
 Heart Attack: 
 Ulcer: 
 GERD: 
 Blood Clots: 
 Bladder: 
 Seizures: 
 Arthritis: 
 Hepatitis: 
 Cancer: 
 Skin Cancer: 
 Melanoma: 
 Keloids: 
 HIV: 
 AIDS: 
 Other: 

Please list all treating physicians for any conditions checked above:

Name of treating physician: 
 Treating physician phone number: 
Name of treating physician: 
 Treating physician phone number: 
Name of treating physician: 
 Treating physician phone number: 

Surgical History

 
Reaction to anesthesia including dental? 
 If you have had reactions, please list symptoms here: 
Past surgeries? 

Please list past surgeries here:

Past surgery type: 
 Date: 
Physician Name: 
Past surgery type: 
 Date: 
Physician Name: 
Past surgery type: 
 Date: 
Physician Name: 

Family History

 
Are mother and father currently living? 
 If not, what was cause of death? 
How many siblings do you have? 
Are siblings currently living? 
 If not, what was cause of death? 
 

Social History

 
 Occupation? 
 How long at occupation? 
 Amount of daily sun exposure? 
Do you drink alcohol? 
If yes, how many drinks per day? 
Do you smoke? 
If yes, how many cigarettes per day? 
Do you use electronic cigarettes? 
Do you use illegal drugs? 
Do you use tanning booths? 
If yes, what is the last date you tanned? 
Any international travel within last 6 months? 
Any exposure to chemicals? 
If female, are you currently pregnant? 
Are you a vegetarian? 
Do you currently wear sunscreen? 
 What are your hobbies? 
 

By signing this form you attest that all information provided is true and accurate at date listed on this form. Furthermore, by signing this form, you hereby release M.D. Claiborne & Associates, L.L.C. from all responsibilities and liabilities whether financial, medical or loss of life associated with treatment and care provided by its physicians and staff based on the information you have listed. We reserve the right to refuse treatment based on any finding of false or inaccurate information contained on this form.



 
 Please type your full name to acknowledge that you understand and agree: 

 

CANCELLATION POLICY


To Our Patients:
 
M.D. Claiborne & Associates, L.L.C. is committed to helping you manage and maintain your skincare needs. When you schedule an office visit or surgery appointment with our physician or laser specialist, that time is reserved exclusively for you. If you know that you will be unable to keep your office visit, surgical or cosmetic appointment, we ask you to show consideration by calling our office in advance. Providing our office with adequate notice will allow us to offer that appointment time to another patient. We do understand that on occasion unforeseen circumstances do arise and the need to cancel your office visit or scheduled surgery without advanced notice may be unavoidable. We will address those situations with you when and if they arise.

In the event you do not cancel/reschedule your office visit, scheduled surgery or cosmetic appointment, the following fee will be applied to your account:

All fees applied to your account will require payment in full prior to scheduling any future appointments. If fees are not paid, your account will be placed with an outside collection agency.

Please note: these fees are not billable to your insurance carrier and are the patient’s responsibility. Per your carrier and the contract agreement with the physician these fees are permissible and collectible.

We thank you for working with us to ensure that services are provided to all our patients in the best manner possible. Please contact the Office Manager for any questions you may have regarding this policy.


I have read and understand the no show/cancellation policy of the practice and agree to be bound by the terms as stated. I also understand the practice reserves the right to amend this policy as needed.

 
Please sign to acknowledge that you understand and agree:
 

Reset Signature

 
 Please type your full name to acknowledge that you understand and agree: