Appointment Form We are HIPPA Compliant For more information regarding HIPPA click here for you your copy of our privacy notice. Select a date (required) Select a time (required) 09:30 AM - 10:00 AM10:00 AM - 10:30 AM10:30 AM - 11:00 AM11:00 AM - 11:30 AM11:30 AM - 12:00 PM01:00 PM - 01:30 PM01:30 PM - 02:00 PM02:00 PM - 02:30 PM02:30 PM - 03:00 PM03:00 PM - 03:30 PM03:30 PM - 04:00 PM04:00 PM - 04:30 PM04:30 PM - 05:00 PM Patient Informatiom Dr./Mr./Mrs./Ms. DOB Age # of Children Marital: Single Married Divorced Widowed Seperated Social Security #: Address Information Street: City: State: Zip: Home Phone: Work Phone: Cell Phone: Occupation: Employed By: Employer's Address Information Street: City: State: Zip: Phone: Other family members who are patients here: Yes No Insurance Information Insurance Company: Policy #: Policy Holder Name: ID/Group #: Insurance Company Address Street: City: State: Zip: Medicare: Yes No Medicare #: Medicaid: Yes No Health Information Reason for visit: Previous treatment for this: By Dr. Dates Previous skin disease/skin surgery Skin Disease in family Allergies List all meds taken in past month: Name & Dose: Name & Dose: Name & Dose: Name & Dose: Please check if you have the following (past or present): Heart Disease Lung Disease Stomach Disorder High Blood Pressure Hormone Problems Drug/Alcohol Problems Kidney Disease Hepatitis/Liver Disease Cancer Diabetes Nervous Disorder Poor Healing or Scarring Other Medical Problems Major Surgery Health Issues of Interest to You: Hair Loss (pt or spouse) Spider Vein Rx (face or legs) Body Contouring/Fat Removal Laser Treatment (birth marks, brown spots, or tattoos) Skin Aging/Sun damage protection Wrinkle Correction or Improvement Scar Treatment Chemical Peels Treatment or Excess Eyelid Skin Psoriasis Esthetician Services: Facials Skin Care Products Natural Fragrances Other In case of Emergency contact: Family Doctor: How did you hear about us? My doctor, whose full name is My insurance company The Yellow Pages An ad/article in Radio/TV Station A friend or family member Another person not listed above Other For cosmetic or self-pay patients only: We respectfully request that you take care of your account each time that service is rendered, even if insurance is expected to reimburse you. Please do not hesitate to ask about fees - the staff will be happy to discuss them with you. I authorize and consent to the release of prior medical records and information to Dr. Swinehart. I also agree to pay in full all charges rendered by the CDC, regardless of the status of insurance reimbursement, and (for outstanding accounts) agree to assign all insurance benefits to the Colorado Dermatology Center, Inc. I plan to pay by: Check Credit Card Cash Click to give permission to transmit information