New Patient Registration and Medical Information Form

Patient Information

Only complete this form if you already have an appointment scheduled.

Patient's Name (Last) *

Patient's Name (First) *

Street Address *

City *

State/Province *

ZIP / Postal Code *

Home #

Work

Cell *

*Email Address *

Pharmacy #

Sex *MaleFemaleOther

Date of Birth *

Age

Marital Status

Name of Spouse

Emergency Contact *

Relation *

Cell *

Are you employed?YesNo

If yes, what is your occupation?

Name of employer

Work Address

City

State/Province

ZIP / Postal Code

Did your Primary Care Physician refer you?YesNo

PCP Name

PCP Telephone

PCP Address

City

State/Province

ZIP / Postal Code

If no, how were you referred?

Insurance Information

What is your PRIMARY Insurance? *

I understand that it is my responsibility to know if Ingleton Dermatology is in network with my insurance plan. I have contacted my insurance provider, and I have received confirmation the Ingleton Dermatology is in network. I also understand that if Ingleton Dermatology is not in network with my insurance, I am responsible for any charge(s) that I may incur.

I understand that if my insurance carrier requires a referral, I will bring a referral or assume financial responsibility for all charges incurred. In addition, it is my responsibility to inform Dr. Ingleton's staff of any changes with regard to my insurance coverage prior to my visit. I will also assume financial responsibility for all charges incurred if I fail to present verification of insurance coverage (ID Card).

I authorize payment of medical benefits to the Physician for all services provided. Some insurance carriers will only pay for services that are determined to be "medically reasonable and necessary." I understand that if my insurance carrier determines a particular service not to be "reasonable and necessary" they may deny coverage for that service. In the event that coverage is denied, I agree to be responsible for payment.

*If you provide an email address to us; we may email office correspondences and billing statements to you from time to time. If you do not want either of these, please check the box(es) below.I do not want office announcements or special notifications from the office emailed to me.I do not want statements emailed.

Past Medical History

What is the reason for your visit today? *

List any chronic medical conditions

List any known allergies to medication

List any chronic medications that you are currently taking

For women: Are you pregnant? *YesNo

Are you breast-feeding? *YesNo

Do you have a personal history of pre-cancers / atypical moles / skin cancers? *YesNo

If "yes", what type?

Do you have any prior history of chronic skin conditions? *YesNo

If "yes"PsoriasisEczemaOther

Other

Family History

Is there a family history of skin cancer? *YesNo

If known, please describe (i.e., family member, type of cancer)

Any family history of skin conditions? *YesNo

If yes, please list

Social History

Do you have occupational sun exposure? *YesNo

Past sun exposure *LowModerateSignificant

Daily sunscreen used on face? *YesNo

Review of Systems

(check all that apply)

For All Patients

It is recommended that you have a complete examination of the skin at your first visit to a dermatologist. This requires you to be appropriately gowned to enable the doctor to examine your skin surface for any undetected benign or malignant growths. Do you wish to have this examination? *YesNo

Name of person filling out this form *

Relationship, if not patient

Office Policies

Patient Consent for Use and Disclosure of Protected Health Information

I hereby acknowledge the receipt of Ingleton Dermatology Notice of Privacy Practices. I understand that a copy of the notice can be provided to me upon request.
I understand that Ingleton Dermatology reserves the right to change the notice and that I can obtain a copy of such changes upon request.
I understand that Ingleton Dermatology reserves the right to use and/or disclose my health information which specifically identifies me or which can be reasonably used to identify me to carry out my treatment, payment and health care

Notice of Cancellation and Rescheduling Appointment Policy

If you are unable to make your scheduled appointment, please call our office at 212-673-7100 at least 2 days in advance of your scheduled appointment date to cancel or reschedule. If you do not cancel at least 2 days in advance of your scheduled appointment, you will incur a cancellation fee of $50.00 per 15 minute time slot.

Prescription Re-fills and Prior-Authorizations

In order to better serve you, we ask that you:

Please call for a refill when:

You notice that you have half a bottle/jar/tube
It is at least two weeks before your vacation, business trip, wedding and any other special
- Always have your pharmacy phone number available when calling for a prescription
- Please include your pharmacy phone number when leaving a voicemail.
- Please give us at least 48 hours when returning phone calls related to prescription refills.

Our office is NOT responsible for prior authorizations. If your insurance requires prior authorization, we highly recommend using specialty pharmacies. Our office will provide a list of pharmacies that you may use. If you decide to use your local pharmacy, such as Duane Reade, Walgreens, CVS and Rite Aid, you may be denied prescription coverage.

Consultation Fees

At Ingleton Dermatology, we provide both Medical and Cosmetic Consultations.

Cosmetic consultations and procedures are not covered by any insurance.
1. These consultations refer to the discussion of:
  - Antiaging Injectable (Botox, Filler)
  - Hyperpigmentation
  - Evening of complexion
  - Skin tightening
  - Lasers
  - Hair Removal
  - Acne Scarring
  - Microdermabrasion
  - Chemical Peels
2. If we Do Not participate with your medical insurance, you are a Self-Pay patient, and you are financially responsible for your medical consultation.
3. If we participate with your medical insurance, we will submit the medical portion of your visit to your insurance
4. If you discuss a cosmetic issue with the provider, you are responsible for a cosmetic consultation fee or procedures regardless of whether or not we are in network with your insurance.
5. Please speak with the medical assistant to confirm whether or not your appointment is medical and/or

Below are a couple examples of how this works:

Accepted Insurance

Ex. You are a new patient that has an insurance we accept, and your main reason for a visit is to discuss a rash on your back. However, you also want to learn about hair removal options. In this case, the consultation regarding your rash will be sent to your insurance, and you will be financially responsible for your copay/deductible. You are also financially responsible for a cosmetic consultation about hair removal.

Insurance we do not accept

Ex. You are a new patient that has an insurance we do not accept, and you are experiencing an eczema flare up. However, you are also interested in Botox. In this case, you will be financially responsible for the consultation regarding eczema. You are also responsible for a cosmetic consultation about Botox.

After three years of not being seen by a doctor in this office, you are legally considered to be a new patient. You will be subject to the New Patient Consultation Fees.

Consultation prices do not include the price of any procedures, products or prescriptions that may be recommended. Cosmetic procedures are not covered by insurance.

If you have an insurance we accept, medical procedures will be submitted to your insurance. You will be responsible for your copay/coinsurance/deductible.

I understand and acknowledge the above office policies.

Signature of Patient *

Today's Date *