Patient Forms Sign & Fill New Patients Please fill out this form and bring it with you for your first visit. "*" indicates required fields Step 1 of 7 – Initial Questions 14% CompanyThis field is for validation purposes and should be left unchanged.Initial QuestionsName*Today's Date* MM slash DD slash YYYY Are you the patient?* Yes, I am the patient. No, I am signing on the patient’s behalf. Relationship to the Patient*Do you have any of the following?* Heart Failure Coronary Artery Disease (CAD) Chronic Obstructive Pulmonary Disease (COPD) Diabetes None Do you smoke?* Yes No If any, how many alcoholic drinks per day do you consume?Did you receive the flu vaccine before this past flu season?* Yes No Have you received the pneumonia vaccine?* Yes No Have you received the COVID-19 vaccine?* Yes No Primary Care PhysicianPCP NamePCP Primary PhonePCP AddressMonth/Year of Last Visit?Emergency ContactEmergency Contact Name*Emergency Contact Phone*Emergency Contact Relationship* Patient InformationPatient Name* First Last Patient Gender*Patient Date of Birth* MM slash DD slash YYYY Patient Email Patient Phone Number*Your Address* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Primary Insurance / Insurance Policy HolderPatient Name (on Primary Insurance Card)* First Last Social Security #Employer (if applicable)Primary Insurance Company*Primary Insurance ID/Policy #*Primary Insurance Group #*Insurance Verification Signature*By signing, I verify that this is my correct insurance information.Secondary Insurance to FilePatient Name (on Secondary Insurance Card) First Last Social Security # (Secondary Insurance)Employer (if applicable)Secondary Insurance CompanySecondary Insurance ID/Policy #Secondary Insurance Group # Preferred PharmacyPharmacy NamePharmacy PhonePharmacy City/Zip CodeMedicationsList all current medication:*If none, please write “none”.AllergiesList all allergies and reactions if known:*If none, please write “none”. Past Medical HistoryPlease check any of the following medical conditions you currently have:Medical Conditions* Anxiety Arthritis Asthma Atrial Fibrillation Bone Marrow Transplant BPH Breast Cancer Colon Cancer COPD CAD Depression Diabetes End Stage Renal Disease GERD Hearing Loss Hepatitis Hypertension HIV/AIDS Hypercholesterolemia Hyperthyroidism Hypothyroidism Leukemia Lung Cancer Lymphoma Prostate Cancer Radiation Treatment Seizures Stroke None Other Other Medical Condition:*Disease History* Acne Actinic Keratoses Basal Skin Cancer Blistering Sunburns Dry Skin Eczema Flaking or Itchy Scalp Fever/Allergies Melanoma Poison Ivy Precancerous Moles Psoriasis Squamos Cell Skin Cancer None Other Other Disease:*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 relative(s)? Patient Financial Responsibility DisclosurePlease read in full, thank you.Dear Patient, Please be aware that your health insurance defines dermatology as a specialist. It is your responsibility to know what your insurance coverage benefits are. We highly recommend you call the number on the back of your insurance card and ask about your coverage for a specialist office on not only your office visit but also any in office procedures. Please know your deductibles/ co-insurance/ copay or any out of pocket costs that your insurance will not cover fully. This will protect you from any unknown bills you may receive from Lucid Dermatology. Thank you for choosing Lucid Dermatology for your skin care needs. For any further questions regarding this matter please reach out to the Lucid Dermatology Billing Dept at (516) 887-7090 ext. 111 or 134Financial Responsibility Signature*By signing, I hereby attest that I have read and understood my financial responsibility.Cancellation Policy for AppointmentsPlease read in full, thank you.Any time you are unable to keep your appointment, we would appreciate a call in advance from you so that we may cancel your appointment and use the appointment time for another patient. This serves as notice that if you fail to give us a 24-hour notice of cancellation for a medical or aesthetician appointment, there will be a $25.00 cancellation fee. In addition, for cosmetic and surgical excision appointments there will be a $50.00 cancellation fee for failure to provide us with 24-hour notice. These fees are not covered by your insurance. You will bear complete financial responsibility for this fee. Cancellation Policy Signature* First Last Please print your name.Cancellation Policy Signature*By signing, I hereby attest that I have read and understood Lucid Dermatology’s Cancellation Policy.Acknowledgment of Receipt of Notice of Privacy PracticesPlease click on the link below and read in full, thank you.HIPAA Policy Acknowledgement* Yes, I have read in full the Notice of Privacy Practices I understand that, under the Health Insurance Portability & Accountability Act of 1996 (“HIPAA”), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to: • Conduct, plan and direct my treatment and follow-up among the multiple health care providers who may be involved in that treatment directly and indirectly. • Protected health information may be disclosed or used for treatment and payment. • Obtain payment from third-party payers. • Conduct normal health care operations such as quality assessments and physician certifications. I have received, read and understand the Notice of Privacy Practices document containing a more complete description of the uses and disclosures of my health information. I understand that Lucid Dermatology has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time for a current copy of the Notice of Privacy Practices document. By signing this form, you consent to our use and disclosure of your protected healthcare information. Do we have your permission to:Confirm appointments by leaving messages or speaking with family?* Yes No Leave a message on your answering machine?* Yes No Leave pre-medication reminders (if applicable)?* Yes No Speak to household members concerning your care?* Yes No Privacy Practices Signature (Patient Name)*By signing, I hereby attest that I have read, understood, and selected Lucid Dermatology’s Privacy Practices Δ
