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Tel : 561-594-0050
Fax: 888-677-3527
[email protected]
www.junodermatology.com
3801 PGA Blvd. Suite 107, Palm Beach Gardens, FL 33410
PLEASE COMPLETE THE ENTIRE FORM. IF NOT APPLICABLE, AFFIX N/A.
First name:________________________________
Address: _________________________________
Email:
_________________________________
Preferred language:*________________________
SSN:
___________________________
Date of birth:
___________________________
Primary phone # _________________ Type: _____
Secondary phone #________________Type: _____
*Recent government reforms require this information.
This applies to all patients.
Last name: _________________________________________
City________________State:_________ Zip code_______
Employment status: [ ] Employed [ ] Retired [ ] Other _______________
Employer: ___________________ Office # ________________
Student status: [ ] Full [ ] Part School name: ________________
Emergency contact:
_______________Phone#:__________
Emergency contact relationship :________________________
Primary provider: __________________________________
Referring physician: __________________________________
Referral source: [ ] Insurance Directory
[ ] Google
Preferred contact method: [ ] Text [ ] Phone
Gender:
[ ] Male [ ] Female
Race:*
[ ] White [ ] Black/ African American
INSURANCE INFORMATION
[ ] Hispanic [ ] Native Hawaiian [ ] Asian
[ ] Other
[ ] American Indian
Primary insurance: __________________________
Name Policy holder:_________________________
Date of Birth:
________ Relationship:_______
Member #:
__________________________
Group #:
__________________________
Group name:
__________________________
Effective:
__________________________
[ ] Provider [ ] Event
[ ] Other: ___________________________
Marital Status: [ ] Married [ ] Single: ___________________
Ethnicity:*
[ ] Hispanic/ Latino
[ ] Not Hispanic/ Latino [ ] DECLINE
Secondary insurance: ____________________________
Name Policy holder: ____________________________
Date of Birth:
________ Relationship:_________
Member #:
____________________________
Group #:
____________________________
Group name:
____________________________
Effective:
____________________________
PLEASE INDICATE INITIAL:
The information I provided above is truthful and accurate, and any discrepancy may result in further clarification. (Required)
I authorize Juno Dermatology, LLC to furnish information concerning my condition and treatment to my insurance carrier(s). If you do not want
us to submit your visit info to your insurance, the patient/financially responsible party accepts the full financial responsibility for cost incurred during the
visit(s). (Required)
I authorize payment of medical benefits to Juno Dermatology, LLC. (Required)
I understand that I am responsible for any part of the charges that are not covered by my insurance. (Required)
I understand that I will be charged $50 fee for cancellations made less than 24 hours before scheduled appointment. (Required)
I give my permission to Juno Dermatology, LLC to email me promotional offers on products and services. (Optional)
________________________________________________
___________________________________________
SIGNATURE
(Patient or Parent/Guardian if patient is a minor)
TODAY’S DATE
Tel : 561-594-0050
Fax: 888-677-3527
[email protected]
www.junodermatology.com
3801 PGA Blvd. Suite 107, Palm Beach Gardens, FL 33410
Please read carefully and initial each paragraph.
PHOTOGRAPHY
The undersigned patient or legal guardian hereby authorizes Juno Dermatology, LLC to take, use, and copy a photo
of patient, including but not limited to the face. The photo(s) will only be used for purposes of identification and
documentation of the progress of patient's condition. I understand that no photographic image of the patient will be
disseminated outside of Juno Dermatology, LLC for commercial purposes without my further consent.
USE OF PROTECTED HEALTH INFORMATION
I authorize Juno Dermatology, LLC to use and disclose Protected Health Information (PHI)
of the patient for the purposes of carrying out treatment, payment, and healthcare operations (TPO). The complete
description of such uses and disclosures can be found in our Notice of Privacy Practices.
I received a copy of the Notice of Privacy Practices prior to signing this consent.
With this consent, Juno Dermatology, LLC may call and/or send mail to me or to person listed on the Patient
Disclosure form in order to assist them in carrying out TPO. This includes but is not limited to appointment reminders,
insurance items, laboratory results, financial statements and any other information pertaining to my clinical care.
I understand that I may revoke my consent in writing, except for the information that the practice has already
made disclosures of before the consent was revoked. Juno Dermatology, LLC reserves the right to decline treatment to
me/the patient once the consent has been revoked.
_________________________________
Patient's Name
_________________________________
Date
_________________________________
Patient/ Legal Guardian Signature
_________________________________
Printed Name of Guardian
Tel : 561-594-0050
Fax: 888-677-3527
[email protected]
www.junodermatology.com
3801 PGA Blvd. Suite 107, Palm Beach Gardens, FL 33410
Commercial and non-commercial insurance
Juno Dermatology, LLC will bill your insurance(s) for services rendered during your visits provided that your insurance carrier will
make payments directly to Juno Dermatology, LLC.
Medicare
Juno Dermatology, LLC will accept assignment from Medicare. The patient is responsible for the 20% co-payment. If you have a
Medicare supplement, we will file a claim with them provided they will make payments directly to Juno Dermatology, LLC.
Referrals
If your insurance requires a referral from your primary care physician (PCP), please make sure that your PCP has been notified of this
appointment. A copy of the referral must be provided to you and Juno Dermatology, LLC prior to your appointment. Juno Dermatology,
LLC is not responsible for procuring referrals.
Claim Submission
In the event the patient has insurance coverage but cannot provide documentation, charges will be entered as self-pay. Upon the
submission of the insurance card, we will submit a health insurance claim form. Secondary insurance will be billed upon the submission
of proof of secondary insurance. Juno Dermatology has the right to deny use of insurance card if patient's name on the card does not
match that listed on a government issued identification card.
Insurance Release
I authorize Juno Dermatology, LLC to release required information to my insurance company, hospitals and other medical providers
regarding services provided, including medical, laboratory studies, HIV testing, and other medical data related to my care.
Financial agreement
I understand that my insurance contract is between me and my insurance company. In the event the insurance does not pay for billed
services, the balance will be the patient's/ legal guardian's responsibility. Juno Dermatology, LLC will forward the account to collections
if the patient fails to settle the account balance on the due date or fails to make suitable financial arrangements. The patient/legal
guardian will be responsible for collection fees that may include but not limited to court fees, attorney fees, and any other fees incurred
during the collection process. Moreover, I consent to Juno Dermatology, LLC making appropriate inquiry on my credit history in
conformity with legitimate business needs and applicable laws, rules, and regulations.
Forms and Release of Records
The completion of administrative forms about your care and duplication of records is not a part of your routine medical services with
us. We are happy to assist you in any way possible, but we reserve the right to charge appropriate fees for these extra services, based
upon time and effort involved. If you request copies, we charge you up to $15.00 to locate and copy your records, plus postage if you
want them mailed to you. Requests must be made in writing by completing our record release form. There is no cost to provide records
to facilities or physicians that we refer you to see.
_____________________________
____________________________
Patient's Name
Date
________________________________
Patient / Legal Guardian Signature
_______________________________
Printed name of Guardian
Tel : 561-594-0050
Fax: 888-677-3527
[email protected]
www.junodermatology.com
3801 PGA Blvd. Suite 107, Palm Beach Gardens, FL 33410
Patient's name: _______________________________________________________________________
Date of birth: ________________________________________________________________________
Past Medical History:
Asthma
Emphysema
Seasonal/Food Allergies
High Cholesterol
High Blood Pressure
Heart Disease
Heart Murmur
Artificial Heart Valve
Pacemaker/ Defibrillator
Bleeding Disorder
Blood Clots
Thyroid Disease
Diabetes
Kidney Disease
Gastro-Esophageal Reflux
Duodenal or Peptic Ulcer
Inflammatory Bowel Disease
Gluten Sensitivity/Celiac Disease
Hepatitis
Autoimmune Disorder
Neurologic Disorder
Arthritis
Artificial Joints
Cancer (please specify) _____________
Radiation Therapy
Organ Transplant
Tuberculosis
STDs (HPV, herpes, syphilis, gonorrhea,
chlamydia,
other)___________________________
Immunodeficiency/HIV
Emotional Disorder
NONE
OTHER:
____________________________________
______________________________
Past Surgical History (please list any surgeries with dates, if available):
___________________________________________________________________________________________
_____________________________________________________________________________
Skin Disease History :
Acne
Rosacea
Blistering Sunburns
Actinic Keratoses
Basal Cell Skin Cancer
Squamous Cell Skin Cancer
Precancerous Moles (AKA, Dysplastic)
Melanoma
Dry Skin
Eczema
Flaking or Itchy Scalp
Psoriasis
None
OTHER:
____________________________________
____________________________________
____________________________________
________________________
Tel: 561-594-0050
Fax: 888-677-3527
[email protected]
www.junodermatology.com
3801 PGA Blvd. Suite 107, Palm Beach Gardens, FL 33410
Do you wear Sunscreen?
Yes
No
If yes, what SPF? _____
Do you tan in a tanning salon (past or present)?
Yes
No
Do you have a family history of melanoma?
Yes
No
If yes, which relative(s)?
_________________________________________________________________________
_________________________________________________________________________
Any other family history of skin disease:
_________________________________________________________________________
Medications (please enter all current medications, dose and frequency, if known):
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Allergies (please list all allergies):
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Social History:
Cigarette Smoking:
Never smoked
Quit: former smoker
Smoke less than daily
Smoke daily
Alcohol Use:
YES ______________glass/day
NO
Pharmacy:
Name:
____________________________________________________________________
Phone number: ____________________________________________________________________
Zip code:
____________________________________________________________________
Family History:
CANCER: _____________________________
DIABETES:_____________________________
HEART DISEASE: ________________________
HYPERTENSION:________________________
OTHER:_______________________________
Mother | Father | Brother | Sister|
Mother | Father | Brother | Sister|
Mother | Father | Brother | Sister|
Mother | Father | Brother | Sister|
Mother | Father | Brother | Sister|
Tel: 561-594-0050
Fax: 888-677-3527
[email protected]
www.junodermatology.com
3801 PGA Blvd. Suite 107, Palm Beach Gardens, FL 33410
Review of Systems:
Problems with bleeding
Problems with healing
Problems with scarring
(Hypertrophic/keloid) skin
Immunosuppression
Hay Fever
Chest pain
Fever or chills
Night sweats
Unintentional weight loss
Blurry vision
Abdominal pain
Bloody stool
Bloody urine
Joint aches
Muscle weakness
Neck Stiffness
Headaches
YES
YES
YES
NO
NO
NO
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
Seizures
Cough
Shortness of breath
Wheezing
Allergy: Adhesive
Allergy: Lidocaine
Allergy: Topical Antibiotic
Artificial: Heart Valve
Artificial: Joints within 2 yrs
Blood thinners
Rapid Heart Beat
with epinephrine
Pregnancy or planning Preg.
Breastfeeding
Defibrillator
MRSA
Pacemaker
Would you be interested to learn more about cosmetic procedures that we offer?
If yes, please choose from the following:
Botox®Cosmetic
Laser hair removal
Laser for freckles, sun damage
Professional Grade Skin care
Fillers (Juvederm®, etc)
Laser for facial blood vessels
Laser Scar treatment
Customized Facials
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES
YES
YES
YES
YES
Yes
No
Laser skin resurfacing
Microdermabrasion
Chemical Peels
NO
NO
NO
NO
NO
Tel : 561-594-0050
Fax: 888-677-3527
[email protected]
www.junodermatology.com
3801 PGA Blvd. Suite 107, Palm Beach Gardens, FL 33410
I hereby give authorization to speak to the following people regarding my illness/condition.
____________________________
Name
____________________________
Name
____________________________
Name
____________________________
Name
___________________
_____________________
Relationship
Phone number
___________________
_____________________
Relationship
Phone number
___________________
_____________________
Relationship
Phone number
___________________
_____________________
Relationship
Phone number
I understand that this authorization will expire in 1 year unless otherwise specified.
_________________________________
Patient's signature
_________________________________
Patient's name
______________________________
Date
______________________________
Date of Birth