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DERMATOLOGY INSTITUTE

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					                                                DERMATOLOGY INSTITUTE 
           256 Landis Ave. Suite 300  ‐   Chula Vista,  CA   91910    ‐   Tel:  619‐426‐9600    Fax:  619‐426‐4112 
 
 

____/____/____
Mos/Day/ Year

____________________________________
____________________________________
____________________________________
____________________________________
____________________________________                              Appointment Date:  ____/____/_2012_____
                                                                                    Mos/ Day/ Year
                                                                  Appointment Time: ____:____    AM    PM

Dear Sir/Madam:

Thank you for contacting Dermatology Institute for your Medical appointment with Dr. Peter P.
Rullan or Susan E. McKim, PA-C or Berna Moore, PA-C. We look forward to your visit.

In order to help with the time at the office we are sending the forms that you will need to fill out
before your upcoming visit. Please bring the following or send these to our fax 619-426-4112 on
your visit:

                    1. Your Insurance Card, plus your copay amount.
                       (This does not apply to “Cash” Patients or those with “No copay”).
                    2. Driver’s License or Photo ID
                    3. All pages of the completed and signed forms.
                    4. List of all prescribed and over the counter medications that you are taking.
                    5. List of any Supplements/Vitamins that you are presently taking.

If you are not able to fill out the forms before your appointment, please, be sure to arrive 30 minutes
previous to your scheduled time.


Should you have any questions please call at your earliest at 619-426-9600. You may also fax us
at: 619-426-4112.

We hope to see you soon.

Sincerely,


_________________________________
Rev. 1-12-2012
                                                                           DERMATOLOGY INSTITUTE
                                                                              Patient Registration

                                           Today’s Date:                                                                 Chart #: _______________________ (To be completed by Staff)
                                                                              MOS.            DAY          YEAR


First Name                                                      MI:                                                  Last Name:

Birth Date:       MOS.        DAY           YEAR
                                                                SSN:                                                             How did you hear about us?
 Patient
Address:       Number    Street Name:                                                      Apt.                      City                                 State      ZipCode

                                    The section below should ONLY be completed by the patient’s responsible party, if the Patient is a minor.

Responsible Party Name ( if different than patient):                                                                        Birthdate of Responsible Party:                     Mos.        Day             Year

First Name:                                                     MI:                                                  Last Name:
Address:
               Number    Street Name:                                                        Apt.                    City                                  State     Zip Code
SSN:
                                    -                    -


Driver’s License:                                                         Height:                    Weight:                     Ethnicity:
 Work                                                                      Home                        -                                                  Marital Status:         Single                  Married
Phone:                   -                  -
                                                                           Phone:                                            -
                                                                                                                                                                                  Divorced               Widowed
Primary Care Physician:                                                                             Primary Care Phone:

Primary Policy Information: Plan Name:                                                              Policy Holder Name:

Insurance Address:

Policy Holder DOB:                                                                                  Patient’s Relation to Policy Holder:                  Self          Spouse           Child           Other
                                         Mo.                 Day                    Year
Policy ID #:                                                 Group #:                               Policy Holder SSN:
Secondary Policy Information:
                                                                                                    Secondary Policy Holder Name:
Plan Name:
Secondary Policy Holder DOB:                Mo.               Day                   Year            Patient’s Relation to Policy Holder:          Self             Spouse        Child           Other

Policy ID #:                             Group #:                                           Policy Holder SSN:

Employer:                                                                                   Occupation:
School:                                                                                     Student Status:           Full Time               Part Time           Retired         N/A
Employer/School Address:
Cell Phone:                                                                            E-mail Address          __________________________________@____________________________

Emergency Contact Name:                                                               Emergency Contact Phone:                     -                -                Relationship :
PAYMENT FOR OFFICE SERVICES IS DUE ON THE DAY OF THE VISIT. WE WILL ATTEMPT TO BILL CHARGES TO YOUR INSURANCE COMPANY
IF YOU PROVIDE VALID INSURANCE INFORMATION. PAYMENT MAY BE MADE BY CHECK, CASH OR DEBIT/CREDIT CARD.                                 **NOTICE: AN
ADDITIONAL FEE FOR CERTAIN ADMINISTRATIVE SERVICES SUCH AS DISABILITY FORMS, LETTERS OF MEDICAL NECESSITY AND RETURNED
CHECKS WILL BE BILLED AS PATIENT RESPONSIBILITY.**               I understand that if my account becomes delinquent, I will be held responsible for
reasonable attorney’s fees, court costs, and collections costs. I am aware that I may be charged a fee of $35.00 for any appointment missed
without a 24 hours prior notice.
PATIENT-PHYSICIAN AGREEMENT: I, the undersigned, authorize Dermatology Institute to release any information acquired in the course of
my examination or treatment, to my insurance company(s) or other physicians and medical facilities. I understand that the medical insurance I
have may not or not completely cover the fee(s) for professional services rendered to me, and I agree that I am responsible for said fee(s). I
authorize payment directly to and assigned to Dermatology Institute, the surgical/medical benefits for their services. A photocopy here forth shall
be valid as the original. I am aware that I may inquire of my physician the fee(s) for any professional services required and/or rendered.

DATE:            Mos.            Day              Year             SIGNATURE OF PATIENT/GUARDIAN: __________________________________________________________________________
Referring Physician: ________________________________________

Reason for Today’s Visit: __________________________________________________________________________


CURRENT CHRONIC PROBLEMS :                           □No Known
Name:



ALLERGIES :              □No Known
SUBSTANCE                REACTIONS ( CIRCLE ONE)                                                                   EST.ONSET (DATE OCCURRED)
                         Nausea / Hives / Fast Heart Rate / Swelling / Difficulty Breathing / other:
                         Nausea / Hives / Fast Heart Rate / Swelling / Difficulty Breathing / other:
                         Nausea / Hives / Fast Heart Rate / Swelling / Difficulty Breathing / other:

MEDICATIONS PRESENTLY TAKING:                        □None




PAST MEDICAL CONDITIONS :            □None
CONDITION                            ONSET DATE          RESOLVED             CONDITION                        ONSET DATE      RESOLVED
                                                         DATE                                                                  DATE




PAST MEDICAL SKIN PROCEDURES / SURGERIES ELSEWHERE:                                □None
PROCEDURE                                                            DATE          PROCEDURE                                        DATE




FAMILY HISTORY                       □None
Relationship                         Mother                       Father                       Sister          Brother
Skin Cancer
Acne
Psoriasis
Eczema
Psoriasis
Other Skin Conditions:



SOCIAL HISTORY
Alcohol                         □   None             □     Current    (estimated drinks per week _____ )       □   Past
Tobacco                         □   None             □     Current    (estimated cigarettes per week _____ )   □   Past
                                     INITIAL PATIENT QUESTIONNAIRE 
 
NAME_____________________________DOB__________AGE_______OCCUPATION___________________________ 
REFERRING PHYSICIAN___________________________PRIMARY CARE PHYSICIAN_________________________ 
REASON FOR TODAY’S VISIT:_______________________________________________________________________  
____________________________________________________________________________________________________ 
____________________________________________________________________________________________________ 
DO YOU HAVE ANY ALLERGIES TO MEDICATIONS/ Food? (Please list)________________________________________ 
____________________________________________________________________________________________________ 
ARE YOU SENSITIVE TO LOCAL ANESTHETICS? (Lidocaine/Epinephrine)                    YES       NO 
Please list medical illnesses: _____________________________________________________________________________ 
____________________________________________________________________________________________________ 
____________________________________________________________________________________________________ 
Please list other skin problems:___________________________________________________________________________ 
____________________________________________________________________________________________________ 
Family history of skin problems:__________________________________________________________________________ 
____________________________________________________________________________________________________ 
Please list current medications__________________________________________________________________________ 
____________________________________________________________________________________________________ 
____________________________________________________________________________________________________ 
List all past surgeries (including cosmetic)__________________________________________________________________ 
Had skin cancer?  YES    NO    If Yes, what type? __________________________________________________________ 
Do you have any of the following problems:  (Please circle YES or NO)                
Any hormone problems?                         YES     NO          Do you have a   high  or  low …pain threshold  (choose one) 
Do you smoke?                        YES     NO        Are you diabetic?                                YES     NO 
Do you heal with thick or wide scars?         YES     NO        Have you had Tuberculosis?                        YES     NO 
Do you sunburn easily?                        YES     NO        Have you had hepatitis or blood transfusion?   YES    NO 
Take aspirin or blood thinners?               YES     NO        Do you have herpes (cold sores or genital)?     YES     NO 
History of psychological problems?            YES     NO        Need to take antibiotics before surgery?           YES     NO 
                   
FEMALE PATIENTS:           Pregnant?  YES      NO        Method of birth control__________________________________ 
 
Is your condition work related?      YES    NO     Date of Injury____________  Employer_________________________ 
CURRENT SKIN CARE REGIMEN:  Your facial skin type:   OILY    COMBINATION     DRY     SENSITIVE 
 
Cleanser_________________________         Moisturizer_____________________  Eye Cream___________________ 
 
Sunscreen______________________ Have you used a Retin‐A like cream?  YES  NO     Can you tolerate it? YES   NO 
 
How did you hear about our office? _________________________________________________________________ 
                                
                                
                                             DERMATOLOGY INSTITUTE
                                              PATIENT QUESTIONNARE

                   Participant First Name:                            Middle Initial                                           Last Name:


                    Cell Phone:                                                                                       Other Telephone:


                   Address:                           Apt. No:                 City:                    State:                          Zip Code:

How did you hear               □ My Physician       □            Friend/Family         □   Seminar               □   TV                     □   DVD
about Dermatology
Institute?
                               □ Insurance Provider □            Internet              □   Newspaper             □   Magazine
                               □ Yellow Pages       □            Practice Website      □   Other : ____________________

Email Address:

Tell us what you would like to have to improve problem areas (Please check all that apply): 

□    Acne                               □    Brown Spots/ Freckles                □     Cellulite                                □  Dry Skin 
□    Eczema/ Psoriasis                  □    Droopy Eye Lids                      □      Eye Bags                                □ Hair Removal 
□    Hair Loss                          □    Jowls                                □     Lipo /Body Shaping                       □    Melasma 
□    Rosacea                            □    Scars                                □     Skin Discoloration                       □ Spider Veins 
□    Varicose Veins                     □    Vitiligo                              
□    Lines/ Wrinkles                    □    Eye  Lines                           □     Face Lines                               □    Neck   Lines 
                                        □    Lip  Lines                           □     Cheek area Lines
  
 
                                         
                                                                                                                          \ 




Your Facial Skin Type :                □ OILY                □ COMBINATION               □ DRY                □  SENSITIVE                           




  I  would like to schedule a complimentary Skin Consult with:                    
□    Esthetician                                                            □     Patient Coordinator for Procedure 
 
My main interest is:                
□     Botox                                                                         □ Sclerotherapy ‐ Leg Vein Injections 
□     Fillers:                       □ Artefill,  Silicone      □ Juvederm XC        □ Radiesse       □ Restylane / Perlane       □ Sculptra 
□     Eyelid Surgery:                □ Upper                                 □  Lower   (Blepharoplasty) 
□     Chemical Peels:                □ VI Peel                 □ Glycolic             □ Jessners               □ Salicylic            □  Mélanage 
                                     □ 2 Day Chemical Peel Phenol  Chemabrasion   
□ Laser :                           □ Photofacials for Brown Spots (Intense Pulse Light or IPL, AFT) 
                                    □ CO2 Fractional laser              
                                    □ Pixel Erbium Laser                                                   
                                    □ Accent Radiofrequency‐ Non surgical skin tightening 
                                    □ Soprano Laser Hair Removal for men/ women (Under arms, Legs, Bikini area, etc…) 
                                    □ Medlite  Tatoo Removal                       
□ Liposculpture                                                                    □  Mesotherapy ‐ Fat dissolving Injections      
□ Latisse  (Eyelash growth                              □ Human Growth Formula                              □ Hair Formula 82  (promotes hair      
       formula by prescription)                                Serum TNS                                          growth by prescription only). 
□ Skin Care Products                        □   Bleaching Products                    □   Retinol Pads                         □ Acne Kit 
□    Moisturizer                        □    Cleanser                            □     Toner                                     □ Lip Balm
□    Body Lotion                        □    Hand Lotion                         □     Makeup                                    □ Makeup Primer
□    Sunscreen Lotion                   □    Sunscreen Powder                    □     Eye cream                                 □        Arnica Cream for post  
□    Sun Viser                          □    Brush                               □     Clarisonic Facial Brush                         surgery bruising


 
Rev. 8/2011 
      Acknowledgement of Receipt of Notice of Privacy Practices
    Dermatology Institute, 256 Landis Ave., Suite 300, Chula Vista, CA 91910
                   Office Manager/Privacy Official 619-426-9600


I hereby acknowledge that I received a copy of this medical practice’s Notice of
Privacy Practices. I further acknowledge that a copy of the current notice is posted
in the reception area and that I will be offered a copy of any amended of Privacy
Practices at each appointment.

      I would like to receive a copy of any amended Notice of Privacy Practices
      by e-mail at
      ___________________________________________


Signed:_____________________________                Date:____________________


Print Name:_____________________ ____               Phone:___________________


If not signed by the patient, please indicate:

Relationship:

      Parent or guardian of minor patient

      Guardian or conservator of an incompetent patient

      Beneficiary of persona representative of deceased patient

   Name of Patient:_________________________________________
                                                  FINANCIAL POLICY
Thank you for choosing Dermatology Institute as your health care provider for your dermatology and cosmetic needs. We
are committed to serving and treating you with the utmost care. Please understand that following office and financial
policy is considered part of your treatment. The following is a statement of our policy which you required to read and
sign before any treatment.
   •   It is your responsibility to know your coverage and benefits and if we are a preferred provider of your plan. Please
       be aware that some or all services provided may not be covered by your particular plan. Should your plan not
       cover all services, you will be billed for the services not covered.
   •   We accept assignment of Insurance benefits at the time of coverage. WE CANNOT BILL YOUR INSURANCE
       COMPANY UNLESS FULL AND PRECISE BILLING INFORMATION IS PROVIDED BY YOU AT THE TIME OF
       SERVICE. This includes your primary insurance as well as any secondary insurance you may have. Every effort
       will be made on our part to obtain insurance information from you prior to the time of service. You are required to
       bring supporting documentation with you at the time of service. If you fail to bring this information, you may be
       required to pay at the time of service or be rescheduled.
   •   If your plan requires a co-payment, has a deductible or percentage you must pay, this amount is due at the time
       of service unless other arrangements are made with the business office. A billing fee of $5.00 will be assessed
       for co-pays not paid at the day of service. Any bills you are responsible for and are not paid within 60 days will be
       assessed a “collection fee” of $20.00 and be charged 18% per annun interest.
   •   Those who do not have a health plan where we are a contracted provider, or have no health insurance at all are
       extended a 30% cash discount from our usual and customary fee schedule. Payment is due before services are
       rendered. We will try our best to help you get the needed care. Access to care for our patients is our priority.
   •   If your insurance company has not paid your account in full within 120 days, you will be billed the balance. If you
                                                 th
       do not pay the entire balance by the 25 of each month, a late charge of $25.00 will be assessed each month.
       Bills that are not paid within 90 days of the first billing will be transferred to an outside collection agency unless
       other arrangements have been made. PLEASE DISCUSS ANY NEED FOR PAYMENT PLANS OR PROBLEMS
       WITH OUR BILLING DEPARTMENT PRIOR TO THE 90 DAYS. WE WILL MAKE EVERY EFFORT TO WORK
       WITH YOU.
   •   Failure to keep the account current will result in our being unable to provide additional medical services to you
       unless prepayment is made for services. You may be discharged as a patient if your account needs to be
       forwarded to a collection agency.
   •   There is a $30.00 service fee for checks returned for insufficient funds or closed accounts.
       We accept VISA, MasterCard, cash, or check.
   •   Please notify us with at least 24 hours notice if you must cancel your appointment in order that we may let another
       patient have your appointment time. Any appointments cancelled less than 24 hours will be charged a $25 to $50
       (depending on the appointment) no show, no cancel fee.
I HAVE READ AND AGREE TO THE ABOVE POLICY. I UNDERSTAND THAT REGARDLESS OF MY INSURANCE, I
AM FINANCIALLY RESPONSIBLE FOR PAYMENT OF SERVICES RENDERED BY DERMATOLOGY INSTITUTE AND
AUTHORIZE RELEASE OF MY INFORMATION TO MY INSURANCE COMPANY FOR PAYMENT OF CLAIMS FOR
SERVICES RENDERED. I ASSIGN ALL INSURANCE BENEFITS TO DERMATOLOGY INSTITUTE. THIS
AUTHORIZATION WILL REMAIN IN EFFECT UNTIL REVOKED BY ME IN WRITING.



_________               _________________                 ________________________________________
Acct #                   Date                                   Signature
                                                DERMATOLOGY INSTITUTE 
           256 Landis Ave. Suite 300  ‐   Chula Vista,  CA   91910    ‐   Tel:  619‐426‐9600    Fax:  619‐426‐4112 
 
Dermatology Institute Front Office




Rev. 1-12-2012

				
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