HairColorado.com

Are you Losing Your Hair?
patientquestionnaireJames M. Swinehart, M.D.
Colorado Dermatology Center
950 E. Harvard Ave, Ste. 630
Denver, CO 80210
(303) 744-1202
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Appointment Form

We are HIPPA Compliant
For more information regarding HIPPA click here for you your copy of our privacy notice.

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Patient Informatiom

Dr./Mr./Mrs./Ms.


DOB

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# of Children

Marital:  Single Married Divorced Widowed Seperated

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Address Information

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Other family members who are patients here:  Yes No


Insurance Information

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Medicare:  Yes No

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Medicaid:  Yes No


Health Information

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Previous skin disease/skin surgery

Skin Disease in family

Allergies

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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
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 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:
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