Digital Patient Registration Forms - Dermatology Specialists of Pasadena

General Information

First Name*

Last Name*

Birthdate*

Sex*

Race*

Ethnic Group*

Contact Information

Home Phone

Work Phone

Mobile Phone

Email*

Preferred Contact Method*

Is it ok to leave a detailed message*

Yes
No

Is it ok for office to send appointment reminders*

Yes
No

Home Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Employment*

Occupation/Profession

Marital Status*

Emergency Contact

Name

First Last

Relation

Phone

Physician Information

Primary Physician/Provider

Referring Physician/Provider

Primary Insurance

Policyholder Name

Relationship to Patient

Policy Holder's Date of Birth

Insurance Company Name

Member ID

Group ID

Secondary Insurance

Yes
No

Secondary Insurance Policyholder Name

Secondary Insurance Relationship to Patient

Secondary Insurance Policy Holder's Date of Birth

Secondary Insurance Insurance Company Name

Secondary Insurance Member ID

Secondary Insurance Group ID

Notice of Privacy Act Practices

HIPAA (Health Insurance Portability and Accountability Act) regulations requires us to provide you, the patient or personal representative a copy of our Notice of privacy practices and for you to sign as an acknowledgement of receipt.

Do you acknowledge receipt of our notice of privacy act practices?*

I acknowledge

Sharing of Information

***Concerning matters of my health, lab results, and appointments, I, the patient/patient representative give permission for Dr. Zohrabian or members of her staff to speak to and share my information with:

Please share with

Share With:*

one per line

Medical History

Past Medical History*

Please Specify*

Past Surgical History*

Please Specify*

Skin Disease History*

Please Specify*

Do you wear Sunscreen?*

Yes
No

What SPF?

Do you tan in a tanning salon?*

Yes
No

Do you have a family history of Melanoma?*

Yes
No

Which relative(s)?

Medications*

Please enter all current medications you currently take

Allergies*

Please enter all allergies

Cigarette Smoking

Currently Smokes
Has smoked in the past
Never smoked
Former Smoker

Alcohol Use:

EtOH- None
EtOH- less than 1 drink per day
EtOH -1-2 drinks per day
EtOH -3 or more drinks per day

Other

Family Medical History

(Only first degree relatives)

Have you had a Pneumonia Vaccine*

Yes
No

Date

Have you had a Flu Vaccine*

Yes
No

Date

Preferred pharmacy

Name, Address, Phone, City or Zip code:

Are you currently experiencing any of the following?

Check any that apply

Symptom*

Other Symptoms

Alerts*

Patient Confirmation

The above information is accurate to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Dermatology Specialists of Pasadena/Narineh Zohrabian MD Inc. or insurance company to release any information required to process my claims.

626-817-9944

800 Fairmount Ave S #312, Pasadena, CA 91105

626-817-9944

General Information

Contact Information

Emergency Contact

Physician Information

Primary Insurance

Notice of Privacy Act Practices

Sharing of Information

Medical History

Are you currently experiencing any of the following?

Patient Confirmation