River Ridge Dermatology New Patient Form

Your IP Address: 54.243.26.210

Please fill out this form and then click the 'Submit' button at the bottom. If you do not want to fill out the online form, click Here for a printable form.


Patient Name

Date of Birth



Last Name

Initial

First Name


Mail Address

Single Married Widowed


Street Address

Phone Home


City

State

Zip

Phone Work


Social Security

Date of Birth

Phone Mobile


Employ. Status

Employer


Gender
Male
Female

Ethnicity
Not Hispanic or Not Latino
Hispanic or Latino
Other

Race
Asian
Black African American
White
Other

E-mail Address


How did you hear about us?


Primary Care Phy


Physician Phone


Referring Physician


Phone Number


Preferred Pharmacy


Pharmacy Location


Pharmacy Phone


Date of Last Visit



Responsible Party Information: Complete this section only if the person responsible for payment is different than the patient

Primary Name on Insurance

Date of Birth

Address

Relationship

Phone Number


Emergency Contact Information


Name


Address


Phone Number


Relationship



Patient Name

Date of Birth


Welcome to River Ridge Dermatology. Our goal is to provide you with the best possible care in a comfortable, friendly environment. In order to minimize the possibility of any miscommunication or misunderstandings we ask that you review the following office policies and indicate your understanding and agreement. If you would like any further clarification, our staff will be happy to assist you. Welcome to the River Ridge Family.

Authorization to Release Information


May we leave messages regarding future appointments on your voice mail or e-mail?

Yes

No


May we leave biopsy or test results on a voice mail?

Yes

No


I authorize River Ridge Dermatology to discuss my care and/or appointments with the following person(s):


Name


Name


Relationship


Relationship


No Show/Cancellation/Late Policies:


• In order to reduce wait time for our patients, we ask that you arrive 5-15 minutes early for your appointment. In addition, your appointment time is reserved specifically for you and in the event that you are unable to keep your appointment, we request enough time to make that appointment slot available to patients that are waiting to be seen. Please review the following policies that apply to all patients and all circumstances.
Late Policy: Appointments will be rescheduled if you are more than 20 minutes late for your scheduled appointment time.
Cancellation Policy: Appointments must be cancelled at least one full business day prior to your scheduled appointment time. Failure to do so will result in the following non-insurance fees being charged to your account.
No Show Fee for Office Visit: $ 25
No Show Fee for Surgery : $100

Payment Policies:


• In order to keep our costs and fees as low as possible we ask that all Co-Pays and Coinsurance amounts be paid at the time of service. Once payment is received from your insurance company, we will send you a statement detailing any refund or balance owed.
• It is the patient's responsibility to know if the provider they are seeing is a participating provider with their medical policy. If we are not a participating provider your insurance company may not pay for some or all of the charges associated with your visit. Any remaining charges not paid by the insurance company will be the patient's responsibility.
• If your insurance requires a referral, it is the patient's responsibility to ensure that we have received the referral prior to their scheduled appointment. If we have not received your referral prior to your appointment you will be responsible for the full amount of any charges that are not covered by your insurance.
In response to the recent challenges of Healthcare Reform, and the increasing number of high deductible insurance plans, River Ridge Dermatology will maintain a credit card on file for all patients with commercial health care plans that have not met their annual deductible. Patients with government health care plans (Medicare, Tricare, and Medicaid) will not be required to place a credit card on file. For those patients who do not wish to leave a credit card on file, services can still be provided when the minimum service fee for each service is paid in full at the time of service.

Consent for HIV, Hepatitis B or C Testing:


• River Ridge Dermatology is required by section 32.1-45.1 of The Code of Virginia, as amended, to give you notice that if an River Ridge Dermatology health care provider, worker or employee should be directly exposed to your blood or bodily fluids in any way that may transmit disease, your blood will be required to be tested for infection with the human immunodeficiency virus (AIDS virus) as well as Hepatitis B and C. A physician or other health care provider will notify you of the results of the test. Under VA code section 32.1-45.1A, you are deemed to have consented to the release of the results to the person exposed. River Ridge Dermatology will only be responsible for any expenses incurred for this testing under the circumstances listed above.

Information Release to Insurance Company:


• I hereby authorize River Ridge Dermatology to furnish information to insurance companies as may be requested for illness or injury. This authorization shall apply to my records or any minor listed above. I authorize payment for these services to be made directly to River Ridge Dermatology.
• I also understand that I am responsible for payment of services not covered by my insurance company and that payment for co-pays are required at the time of service.

I have read and understand the above policies. I have had the opportunity to review the Privacy Practices for River Ridge and consent to be bound by those policies.


Today's Date


Signature of Responsible Party



Printed Name if not Patient


Patient Name

Date of Birth


Past Medical History (Please check all that apply)


Anxiety
Arthritis
Artificial Joints
Asthma
Atrial Fibrillation
Benign Prostatic Hypertrophy (BPH)
Bone Marrow Transplantation
Breast Cancer
Colon Cancer
COPD
Coronary Artery Disease

Depression
Diabetes
End Stage Renal Disease
GERD
Hearing Loss
Hepatitis
Hypertension
HIV/AIDS
Hypercholesterolemia
Hyperthyroidism
Hypothyroidism

Leukemia
Lung Cancer
Lymphoma
Pacemaker/Defibrillator
Prostate Cancer
Radiation Treatment
Seizures
Stroke
Valve Replacement
None

Other



Past Surgical History (Please check all that apply)


Appendix Removed
Bladder Removed
Mastectomy (Right, Left, Bilateral)
Lumpectomy (Right, Left, Bilateral)
Breast Biopsy (Right, Left, Bilateral)
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
Joint Replacement, Knee (Rt, Lft, Bi)
Joint Replacement, Hip (Rt, Lft, Bi)
Joint Replacement with last 2 years
Kidney Biopsy
Kidney Removed (Right, Left)
Kidney Stone Removed
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 Surgery
Testicles Removed (Right, Left, Bi)
Hysterectomy, Fibroids
Hysterectomy, Uterine
None

Other



Patient Name

Date of Birth


Skin Disease History (Please check all that apply)
Acne
Actinic Keratosis
Asthma
Basal Cell Skin Cancer
Blistering Sunburns
Dry Skin
Eczema
Flaking or Itchy Scalp
Hay Fever / Allergies
Melanoma
Poison Ivy
Abnormal Moles
Psoriasis
Squamous Cell Skin Cancer
None

Other




Do you wear Sunscreen?

Yes

No

If Yes, what SPF?


Do you tan in a tanning salon?

Yes

No


Do you have a family history of Melanoma?

Yes

No


If Yes, which relatives?



Medications (Please list ALL current medications)










Do you take any type of blood thinner?

Yes

No


Do you take aspirin daily?

Yes

No



Allergies (Please list ALL allergies)







Are you allergic to Latex?

Yes

No


Are you allergic to Iodine or Betadine?

Yes

No



Social History (Please check all that apply)


Currently Smokes - Daily
Currently Smokes - Not Daily
Has Smoked in the Past

Has Never Smoked

Drug Use
None


Patient Name

Date of Birth


Do you have any of the following?


Pacemaker
Defibrillator
Artificial Joints Replaced in past 2 Years
Artificial Heart Valve
Require Premedication Prior to Surgery
An Allergy to Adhesive
An Allergy to Topical Antibiotic Ointments
Take Any Type of Blood Thinner
Pregnant or Planning to get Pregnant
An Allergy to Lidocaine
Experience Rapid Heartbeat with Epinephrine
Experience Yeast Infections when taking Antibiotics
Experience G.I. Upset with Antibiotics
None