Helios Dermatology
653 N Town Center Drive - Suite #114 – Las Vegas, NV 89144
Phone: (702) 343-3522 – Fax (702) 992-0310
Name (First, Middle, Last) : ______Date of Birth: ______
Address: ______(City, State, Zip): ______
Social Security #: ______Sex: M F Marital Status: Single Married Widowed Divorced
Home Phone:______Cell Phone: ______Email: ______
Maiden Name:______Employment Status: Employed Part-Time Student Full-Time Student Other
Employment Information
Employer: ______Occupation: ______
Name of Insured: ______Date of Birth of Insured: ______
Address: ______ (City, State, Zip): ______
Social Security #: ______Relationship to Patient: mom dad husband wife self other: ______
Occupation: ______Employer: ______Employer Phone: _______
Insurance Information
Name of Primary Insurance: ______Subscriber: ______
ID Number: ______Group #: ______Phone#: ______
Claims Mailing Address: ______ (City, State, Zip): ______
Secondary Insurance: ______Group #: ______ID Number: ______
Claims Mailing Address: ______ (City, State, Zip): ______
Relative to Contact in Case of Emergency
Name: ______Phone: ______Relationship to Patient: ______
Address: ______ (City, State, Zip): ______
How Were You Referred to Our Office?
Website By a Doctor By a Patient Insurance Provider Directory Other PCP / OB/GYN ______
I voluntarily consent to receive medical and health care services that may include diagnostic procedures, examination, and treatment. I hereby authorize medical treatment for the above named patient and fully acknowledge that all office visits are on a cash basis and will be paid in full at the time of the visit, unless otherwise contracted by my insurance. I further understand that my insurance policy is a contract between my insurance company and myself and that I am financially responsible to Helios Dermatology for any fees not covered by my insurance. In the event of default on any payments due Helios Dermatology, I agree to pay all costs of collection including attorney’s fees. I hereby authorize the filing of any insurance in force and direct payment to Helios Dermatology of any amounts due on my claim. I further authorize the offices of Helios Dermatology to release any and all pertinent medical records necessary to facilitate insurance billing and authorize the creditor of his agent to make any employment and insurance verification and release of all information needed to process claims. I hereby assign, transfer, and set over to Helios Dermatology all of my rights, title, and interest to my medical reimbursement benefits under my insurance policy. I authorize the release of any medical information needed to determine these benefits. I understand that I am financially responsible for all charges whether or not they are covered by insurance.
I certify that I have read this form and understand its contents:
Patient or Other Legally Authorized Person: ______Date: ______
Helios Dermatology Name: ______Date: ______
A. PFSH – Brief – Q & A (Please circle the best answer)
Alcohol use ? Y / N ( uses some, rarely, social, moderate, recovering alcoholic, excessive)
Illegal drug use ? Y / N ( amphetamines, cocaine, marijuana, opiates, other______)
Tobacco use ? Y / N ( uses sometimes, quit (time since______), lives w/ smoker, chews tobacco)
(_____Cigs Per ( Day / Week ) ) _____Qty Cigars per ( Day / Week )
B. Personal History of Skin Cancer ? Y / N
Type of skin cancer ( BCCA / SCCA / Melanoma ) Year of Diagnosis: ______Location ______
Type of skin cancer ( BCCA / SCCA / Melanoma ) Year of Diagnosis: ______Location ______
Type of skin cancer ( BCCA / SCCA / Melanoma ) Year of Diagnosis: ______Location ______
C. Family History of Skin Cancer / Melanoma ? Y / N
Father Mother Sibling Child ( BCCA / SCCA / Melanoma ) ______
(Maternal) Grandfather Grandmother ( BCCA / SCCA / Melanoma ) ______
(Paternal) Grandfather Grandmother ( BCCA / SCCA / Melanoma ) ______
D. History of Skin Disease ? Y / N
Eczema Psoriasis Lichen Planus Keloids Lupus Vitiligo Autoimmune Disease
E. Have you ever been exposed to HIV ( Aids ) ? Y / N
F. Have you ever had a sunburn in your life ? Y / N
# ______of sunburns total in your lifetime?
When? Childhood Teens Age 20+ Age 30+ Age 40+ ______Other
Occupational / Leisure (Sun Exposure) ______(farmer / lifeguard / hiker / mountaineers / golfing)
G. Have you ever had a blistering sunburn in your life ? Y / N
# ______of blistering sunburns
Use of Tanning Beds ? Y / N
If yes, (how many sessions/year ______, for how many years?______)
H. Do you have seasonal allergies ( Y / N ), Do you have hay fever ? Y / N
Do you have a family history of allergies, hay fever, asthma, sinusitis, or eczema ? Y / N
(family members affected: ______)
I. Do you bleed easily ? ( Y / N )
Do you take blood thinners, anticoagulants or aspirin ? Y / N
J. Do you have any Medication Allergies ? Y / N ______
Anesthetics Codeine Penicillin Tetracycline Aspirin Erythromycin
K. Do you have any non-drug allergies ? Y / N
Food ______Tape ______Other ______
L. Are you Pregnant ? Y / N
Helios Dermatology Name: ______Date: ______
M. Do you have Children ? Y / N If Yes, how many ? ______
Family Status ? ( please circle ) Married Single Divorced Widowed
N. Occupation ? ______
History Given by ? Patient (self) Parent Spouse Guardian Friend
O. Ethnicity / Race ? African American American Indian(native) Caucasian Chinese Filipino
Hispanic Indian / Pakistani Japanese Middle Eastern / Arabic ______
This question is about your grandparents and great ancestors and which countries they originally came from.
% Race / native ancestral country ? Mother______Father ______
(eg: Mother: 100% Scottish, Father: 25% Chinese, 25% Filipino, 50% German)
P. Surgeries (Abbreviated) / Hospitalizations / Serious Illnesses When?
______
______
Q. Current Medications: ______
______
______
R. ROS (Review of Systems) Please indicate any personal history below ( please circle )
Allergy / AIDS / Allergy – Seasonal / Allergy Treatments / Anemia / Arthritis / Joint Deformity / AsthmaBladder Problems / Bleeding Disorders / Bowel problems / Bronchitis / History of Cancer / Chemical Dependency / Chest Pain
Chicken Pox / Chronic Cough / Diabetes / Emphysema / Epilepsy / Fainting / Glaucoma
Hair loss/ thinning / Hay fever / Heart attack / Hearth disease / Heart murmur / High blood pressure / Hepatitis
Herpes / HIV / Irregular heart beat / Kidney disease / Keloids / bad scars / Liver disease / Lupus
Measles / Migraine / Mononucleosis / Multiple sclerosis / Pacemaker / Phlebitis (leg vein inflammation) / Psoriasis
Psychiatric care / Rheumatic fever / Scarlet fever / Seizures / Stomach problems / Stroke / Thyroid problems
Tuberculosis / Typhoid fever / Ulcers / Vaginal infections / Venereal disease / Vitiligo
HIPAA
PATIENT CONSENT FORM
Our Notice of Privacy practices provides information about how we may use and disclose protected health information about you. The Notice contains a Patient Rights section describing your rights under the law.
You have the right to review our Notice before signing this Consent. The terms of our Notice may change.
If we change our Notice, you may obtain a revised copy by contacting our office.
You have the right to request that we restrict how protected health information about you is used or
disclosed for treatment, payment, or health care operations. We are not required to agree to this restriction,
but if we do, we shall honor that agreement.
By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment and health care operations. You have the right to revoke this Consent, in writing,
signed by you. However , such a revocation shall not affect any disclosures we have already made in reliance
on your prior Consent. The Practice provides this form to comply the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
The Patient Understands That:
- Protected health information may be disclosed or used for treatment, payment, or health care operations.
- The Practice has a Notice of Privacy Practices and that the patient has the opportunity to review this Notice.
- The Practice reserves the right to change the Notice of Privacy Practices.
- The patient has the right to restrict the uses of their information but the Practice does not have to agree to those restrictions.
- The patient has the right to restrict the uses of their information but the Practice does not have to agree to those restrictions.
- The patient may revoke this Consent in writing at any time and all future disclosures will then cease.
- The Practice may condition receipt of treatment upon the execution of this Consent.
This Consent was signed by: ______
(Printed Name – Patient or Representative)
______/____/______
(Signature) (Date)
Relationship to Patient: ______
(if other than patient)
Witness: ______
(Printed Name – Practice Representative)
______/____/_____
(Signature) (Date)