Appointment Form

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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

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.

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Appointment Form

Patient Informatiom

Address Information

Employer's Address Information

Insurance Information

Insurance Company Address

Health Information

How did you hear about us?