Download New patient forms - Comprehensive Dermatology

ERICA MAILLER-SAVAGE, MD, FAAD
Board-certified Dermatologist
and Mohs Micrographic Surgeon
CHRISTOPHER SAVAGE, MD, FACS
Board-certified Facial Plastic Surgeon
Date of visit: _______________________________
Name: _______________________________________________ SS#: ____-____-_____ DOB: ____/____/____
Race: _______________________ Ethnicity: ______________________ Language: _____________________
Reason for your visit today: ______________________________________________________________________
Referring physician: __________________________________ PCP: _____________________________________
Best number to reach you for your test results: _____________________ May we leave a message? □ Yes □ No
□ Male □ Female Age: __________ Height: __________ Weight: __________
If female, are you pregnant or think you could be pregnant? □ Yes □ No
Breastfeeding?: □ Yes □ No
Preferred pharmacy: __________________________________ Pharmacy phone: __________________________
Past Medical & Surgical History (Please list any diseases or conditions that you have now or have ever had )(DO NOT LEAVE BLANK)
□NONE
___________________________ _________________________ _________________________
___________________________ ___________________________ _________________________ _________________________
___________________________ ___________________________ _________________________ _________________________
Have you ever had skin cancer? □ Yes □ No
Do you take antibiotics before surgery due to artificial heart valves or artificial joints? □ Yes □ No
Do you have an allergy to latex, lidocaine or iodine? □ Yes □ No
Do you develop keloids after surgery? □ Yes □ No
Family History: If any blood relative has any condition listed below, check and specify which blood relative
[Ex: □ Mother/Father/Sister/Brother/Child/Uncle/Aunt/Grandparent]
Autoimmune Disease
Colon Cancer
Diabetes
Glaucoma
Premature Coronary Dis.
□ ___________
□ ___________
□ ___________
□ ___________
□ ___________
High Blood Pressure
High Cholesterol
Liver Disease
Lung Disease
□ ___________
□ ___________
□ ___________
□ ___________
Melanoma
Obesity
Skin cancer
Thyroid Disease
□ ___________
□ ___________
□ ___________
□ ___________
Medications (Please list all of your current medications, including vitamins, supplements and herbal medications)
___________________________ ________________________ ________________________ ________________________
___________________________ ________________________ ________________________ ________________________
___________________________ ________________________ ________________________ ________________________
Allergies □ None
___________________________
___________________________
___________________________
___________________________
___________________________
Social History
Do you drink alcohol? □ No □ Yes
Do you smoke? □ No □ Quit/How long ago __ □ Yes/Packs per day?______
Do you use illegal Drugs? □ No □ Yes _________________________________
What is your occupation? __________________________________________________________
What are your hobbies? ___________________________________________________________
201 N. Lakemont Ave, Suite 100 Winter Park, FL 32792 407.339.7546p 407.339.7547f
Caring for you and the skin you’re in
ERICA MAILLER-SAVAGE, MD, FAAD
Board-certified Dermatologist
and Mohs Micrographic Surgeon
CHRISTOPHER SAVAGE, MD, FACS
Board-certified Facial Plastic Surgeon
New patient information form
Date: ____________
Patient Name: ___________________________________________
⃝ Male ⃝ Female
Birthdate: __________ Social Security #: _________________ Email Address: _____________________
Address: __________________________________ Apt: _____ City: ___________________ State: _____
Zip: __________ Home Phone: _____________________ Cell Phone: ____________________
Check appropriate box: Minor Single Married Divorced Widowed Separated
Whom may we thank for referring you? _________________________________________
Emergency Contact: _______________________Relationship: __________Phone: __________________
_____________________________________________________________________________________
Primary Insurance Information
Guarantor of policy: _______________________________ Relationship to patient: _________________
Birthdate: __________ Insurance Company: __________________________ Id#: ___________________
Secondary Insurance Information
Guarantor of policy: _______________________________ Relationship to patient: ________________
Birthdate: __________ Insurance Company: __________________________ ID#: __________________
201 N. Lakemont Ave, Suite 100 Winter Park, FL 32792 407.339.7546p 407.339.7547f
Caring for you and the skin you’re in
ERICA MAILLER-SAVAGE, MD, FAAD
Board-certified Dermatologist
and Mohs Micrographic Surgeon
CHRISTOPHER SAVAGE, MD, FACS
Board-certified Facial Plastic Surgeon
Communication/Privacy Consent Form
Patient Name ___________________________________ DOB ________________________
Due to the HIPPA regulations and the number of patients who have voicemails and/or answering machines on
their telephones, we need some information about how to better communicate with you.
Occasionally it is necessary that we call patients regarding a surgery or appointment time change, test results, and/or
billing matters.
Please answer the following questions so that we can contact you in the most efficient way possible.
May we leave a message on your answering machine at your home?
YES
NO
N/A
May we leave a message on your cell phone?
YES
NO
N/A
May we leave a message on your spouse’s cell phone?
YES
NO
N/A
May we call you at work?
YES
NO
N/A
May we leave a message on your voice mail at work?
YES
NO
N/A
If we call you at home, and you are unavailable, may we leave a message with another person?
YES
NO
N/A
If you are available by work or cell phone, list the numbers below:
Work # ________________________________________ Cell # ________________________________
Please list the person(s) (including spouse, if applicable) that you authorize us to release information to.
Name ___________________________ Relationship _____________________ Phone Number(s) ________________________
Name ___________________________ Relationship _____________________ Phone Number(s) ________________________
Name ___________________________ Relationship _____________________ Phone Number(s) ________________________
Name ___________________________ Relationship _____________________ Phone Number(s) ________________________
Patient /Guardian Signature __________________________________ Date _______________________
201 N. Lakemont Ave, Suite 100 Winter Park, FL 32792 407.339.7546p 407.339.7547f
Caring for you and the skin you’re in
ERICA MAILLER-SAVAGE, MD, FAAD
Board-certified Dermatologist
and Mohs Micrographic Surgeon
CHRISTOPHER SAVAGE, MD, FACS
Board-certified Facial Plastic Surgeon
Receipt of Notice of Privacy Practices
Written Acknowledgement Form
Comprehensive Dermatology & Facial Plastic Surgery
I am a patient of Comprehensive Dermatology & Facial Plastic Surgery. I hereby acknowledge receipt of
Comprehensive Dermatology & Facial Plastic Surgery's Notice of Privacy Practices.
Name [please print]: ______________________________________________
Signature: _______________________________________________________
Date: __________________________________________________________
OR
I am a parent or legal guardian of _______________________________________ [patient name]. I hereby acknowledge receipt of
Comprehensive Dermatology & Facial Plastic Surgery's Notice of Privacy Practices with respect to the patient.
Name [please print]: ______________________________________________
Relationship to Patient:  Parent  Legal Guardian
Signature: _______________________________________________________
Date: __________________________________________________________
201 N. Lakemont Ave, Suite 100 Winter Park, FL 32792 407.339.7546p 407.339.7547f
Caring for you and the skin you’re in
ERICA MAILLER-SAVAGE, MD, FAAD
Board-certified Dermatologist
and Mohs Micrographic Surgeon
CHRISTOPHER SAVAGE, MD, FACS
Board-certified Facial Plastic Surgeon
Practice & Payment Policies: Responsible Party
We try to provide you, the patient, with the most appropriate patient centered care at a reasonable cost. To continue to
make this possible we need your help and participation. Here is how:
1. If you are in doubt about whether we accept your primary or secondary coverage, please work with our staff to
confirm coverage in advance. There are a multitude of insurance plans that sound alike but may be different and we may
not have contracted with them to provide covered services.
2. If you have a change in insurance coverage status or coverage information, please inform the front desk when you
schedule your appointment or on check-in at day of service. Accurate insurance information is critical to the timely
determination of covered services.
3. We collect co-payments, prior account balances, and, if necessary, any large deductibles, at time of service. Please
be aware of your plan coverage provisions and your payment status. We would prefer not to, but we reserve the right to
not provide you with service should you be unwilling to make these payments in advance of services.
4. If your particular insurance plan requires it, you need to be aware of, and provide us with either:
a. Prior written referral from your primary care physician or specialist, or
b. Pre-authorization for treatment from your insurance company
5. If you are paying in cash or we have not contracted with your insurance plan, we require payment in full at the time
of service. We accept cash, checks, Visa, Mastercard and Care Credit. Payment plans can only be arranged in advance. Any
checks returned for insufficient funds will be charged a $25 handling fee, in addition to any bank service fees.
6. We are happy to provide you with an estimated or final itemized bill. If you are paying in cash and/or submitting
separately to your insurance company, please ask us for a preliminary estimate before we provide you with any services
and a final itemized bill when we have completed those services.
7. Because insurance plans vary considerably, we cannot predict or guarantee what part of our services will or will not
be covered. We forward requests for payment coverage of billed services to our contracted insurance companies on a
timely basis and only bill you directly for any non-covered amounts following your insurance company’s determination of
benefits.
8. Since we have provided a service we expect to be paid for that service. Our policy is that your remaining unpaid
balances for services provided are due within 25 days of our billing date. If, for some reason, you are unable to make this
payment on a timely basis, please contact our billing and collections department. We prefer not to forward your account
to a collection agency for servicing, but that may be necessary after your account is 90 days past due and you have not
made prior arrangements with our billing and collections department.
Insurance plans are third party payers and have only contracted with us to provide payment for covered
services. The contract for the actual services provided is between you and our practice and you are
ultimately responsible for payment. Insurance plans can, at times, be challenging to understand. When in
doubt, let us help you resolve any issues of covered services in advance, so you can focus on what you are
here for: the best medical treatment we can provide. If you have any questions, please do not hesitate to ask
any member of the staff.
Please acknowledge by signing below:
Responsible Party Signature: ______________________________________
Please Print Your Name: ______________________________________
Relationship to patient: ______________________________
201 N. Lakemont Ave, Suite 100 Winter Park, FL 32792 407.339.7546p 407.339.7547f
Caring for you and the skin you’re in
ERICA MAILLER-SAVAGE, MD, FAAD
Board-certified Dermatologist
and Mohs Micrographic Surgeon
CHRISTOPHER SAVAGE, MD, FACS
Board-certified Facial Plastic Surgeon
Cosmetic Interest Questionnaire (Optional)
Name: ____________________________________ Date: _______________________
For many people, changes in physical appearance with aging can have a significant impact on self-confidence and even
quality of life. Fortunately, today there are many minimally invasive cosmetic treatments available to enhance and
improve one’s appearance, and reverse signs of aging.
All of our cosmetic products and services are performed or prescribed by the physician, Christopher Savage, MD.
Please let us know if you are interested in any of the following:
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Botox
Dysport
Injectable fillers (Radiesse and JUVÉDERM)
Scar revision
Rhinoplasty (nose reshaping)
Blepharoplasty (eyelid surgery)
Facelift
Otoplasty (ear re-shaping)
Chin and lip implants
Chemical Peels
Facials
Would you like to discuss any of the above today?
□ Yes
□ No thank you
Would you prefer the cosmetic consultant
give you a call? □ Yes □ No thank you
What cosmetic procedures, if any, have you had in the past?
_____________________________________________________________________________
Were you pleased with the outcome? □ Yes □ No
If no, why? ___________________________________________________________________
Would you like to be placed on our mailing list to receive information about cosmetic specials?
□ Yes
□ No thank you
If yes, best way to reach you? □ E-mail □ Regular mail
Email address (if preferred contact) ______________________________________________
201 N. Lakemont Ave, Suite 100 Winter Park, FL 32792 407.339.7546p 407.339.7547f
Caring for you and the skin you’re in