Medical History and Intake Form First Name(Required) Last Name(Required) Date of Birth(Required) Email Address(Required) Race American Indian or Alaskan Native Asian Black/African American Native Hawaiian or Other Pacific Islander White Decline to specify Other Ethnic Group Hispanic Latino Not Hispanic or Latino Unknown Decline to specify Preferred Language English Decline to specify Other How did you hear about our clinic?Choose an Option(Required) Physician Friend or Relatives Google Social Media Other Who is your primary care provider?First Name Last Name Credential M.D. D.O PA-C ARNP PhoneWhat is the name of the provider who referred you to our clinic?First Name Last Name Credential M.D. D.O PA-C ARNP PhoneOur Providers participate in E-Prescribing. Please provide the following informationPharmacy Name PhoneAddress Street Address City Past Medical History (Check all that apply. If none, please check none) None Atrial Fibrillation CVA-Stroke Coronary Artery Disease Diabetes End Stage Renal Disease Leukemia Lymphoma Radiation Treatment Past Surgical History (Check all that apply. If none, please check none) None Basal Cell Cancer Surgery Squamous Cell Cancer Surgery Knee Joint Replacement (Right, Left, Bilateral) Hip Joint Replacement (Right, Left, Bilateral) PTCA (angioplasty, heart stent) Biological Heart Valve Replacement Mechanical Heart Valve Replacement Pacemaker Heart Transplant Skin Disease History (Check all that apply. If none, please check none) None Actinic Keratosis (AK's) Basal Cell Skin Cancer Dysplastic nevus of skin (precancerous moles) Melanoma Psoriasis Squamous Cell Skin Cancer Do you wear sunscreen? Yes No What SPF? Family History of Melanoma? Yes No If yes, whom? Medications (All current medications including non-prescription and birth control; if none, mark N/A) Allergies (Non-Seasonal) (Please list any allergies that you have, and the reaction you had. if none, mark N/A) Social historySmoking History Non-Smoker Former Smoker Current Smoker Alcohol History None 1 or less per day 1-2 per day 3 or more per day IV Drug Use No Yes Immunizations Influenza Yes No Recommended by primary care but refused? What Date? Pneumonia Yes No Recommended by primary care but refused? What Date? Review of SystemsSwollen Lymph Nodes Yes No Pregnant or current trying to become pregnant Yes No Changing Moles; Other than primary reason for visit Yes No Problem with Healing Yes No Chest Pain Yes No Shortness of Breath Yes No Cough Yes No Unintentional Weight Loss Yes No Fever or Chills Yes No Headaches Yes No Anxiety Yes No Do you have a Defibrillator? Yes No Do you have a Pacemaker? Yes No Do you have an Artificial Heart Valve? Yes No Have you had Artificial Joint Surgery in the past 2 years? Yes No History of Rapid Heart Beat with Epinephrine? Yes No Are you taking Blood Thinning Medication? Yes No Do you have a history of Bleeding Problems? Yes No Do you require Antibiotics prior to procedures? Yes No History of Allergy to Band Aids or Adhesive Tape? Yes No History of Keloid or Hypertrophic Scarring? Yes No History of MRSA (Resistant Staph Infections)? Yes No Do you have HIV/AIDS? Yes No Do you have a history of Hepatitis B or C? Yes No Patient InformationName First Middle Last Gender Date of Birth Social Security Number Marital Status Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email Address: Employer Job Title Home PhoneCell PhoneWork PhoneMay we leave a message on voicemail/answering machine for appointments, test results, and instructions? Yes No Phone number we should leave a message atPerson to Notify in the Event of EmergencyName Relationship PhoneInsurance Party Information (Copayments and deductibles are expected at time of service)Primary Insurance Policy Holder's Name Policy Holder DOB/Relationship to Patient Subscriber ID Secondary Insurance Policy Holder's Name Policy Holder DOB/Relationship to Patient Subscriber ID Release of Medical Records Information I authorize SSCO to release information with regard to my care and treatment to the following individuals/family members:Name Relationship PhoneName Relationship PhoneLegal Information Assignment of Benefits: The above information is true to the best of my knowledge. I authorize my insurance benefits to be paid directly to Skin Surgery Center of Oklahoma and its related companies. I understand that I am financially responsible for any balance. I also authorize Skin Surgery Center of Oklahoma and its related companies, or insurance company to release medical information required to process claims. Notice of Privacy Practices: I have read or been offered a copy of Skin Surgery Center of Oklahoma Notice of Privacy Practices (NPP), which explains how my medical information will be used and disclosed. I authorize the release of my medical information necessary to provide care and bill on my behalf. I understand I am entitled to a copy of the NPP. I authorize pictures of myself and of clinical focus areas to be stored in my medical record. Consent for Communication: I understand Skin Surgery Center of Oklahoma will send appointment reminders and information on services via telephone, text message, and/or email based on contact information I provided. I understand that I will have the option to opt out of future text/email reminders. Payment Policy: Payment is due at time of service including copays, deductibles, non-covered and cosmetic procedures, and prior balance due. I understand I am responsible for all charges for services rendered on my behalf, or on behalf of my dependents, less any amount paid by insurance to Skin Surgery Center of Oklahoma and its related companies. Legal: This form applies to Skin Surgery Center of Oklahoma and its related companies.