About Meet Dr. Zohrabian Services Forms Online New Patient Registration Forms Printable New Patient Forms Authorization for Medical Records Consent to Treat Minor Financial & Office Policies Notice of Privacy Practices Billing Insurance Accepted Billing Office Pay Bill Online Contact Purchase Skincare Products 626-817-9944 800 Fairmount Ave S #312, Pasadena, CA 91105 Patient Portal 626-817-9944 Patient Portal About Meet Dr. Zohrabian Services Forms Online New Patient Registration Forms Printable New Patient Forms Authorization for Medical Records Consent to Treat Minor Financial & Office Policies Notice of Privacy Practices Billing Insurance Accepted Billing Office Pay Bill Online Contact Purchase Skincare Products General InformationFirst Name*Last Name*Birthdate* Date Format: MM slash DD slash YYYY Sex*Race*Ethnic Group*Contact InformationHome PhoneWork PhoneMobile PhoneEmail* Preferred Contact Method*Home PhoneWork PhoneMobile PhoneEmailIs it ok to leave a detailed message*YesNoIs it ok for office to send appointment reminders*YesNoHome 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 FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Employment*EmployedSelf-EmplayedStudentRetiredOccupation/ProfessionMarital Status*MarriedPartnerSingleDivorcedOtherEmergency ContactName First Last RelationPhonePhysician InformationPrimary Physician/ProviderReferring Physician/ProviderPrimary InsurancePolicyholder NameRelationship to PatientPolicy Holder's Date of Birth Date Format: MM slash DD slash YYYY Insurance Company NameMember IDGroup IDSecondary InsuranceYesNoSecondary Insurance Policyholder NameSecondary Insurance Relationship to PatientSecondary Insurance Policy Holder's Date of Birth Date Format: MM slash DD slash YYYY Secondary Insurance Insurance Company NameSecondary Insurance Member IDSecondary Insurance Group IDNotice of Privacy Act PracticesHIPAA (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 acknowledgeSharing 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 withNo OneMy Emergency ContactOtherShare With:*one per lineMedical HistoryPast Medical History* Anxiety Arthritis Asthma Atrial fibrillation Bone Marrow Transplantation Breast Cancer Colon Cancer COPD Coronary Artery Disease Depression Diabetes End Stage Renal Disease GERD Hearing Loss Hepatitis High Blood pressure HIV/AIDS High Cholesterol Thyroid Problems Leukemia Lung Cancer Lymphoma Prostate Cancer Radiation Treatment Seizures Stroke None Other Please Specify*Past Surgical History* Mastectomy (Right, Left, Bilateral) Colectomy: Colon Cancer Resection Colectomy: Diverticulitis Colectomy: IBD Gallbladder Removed Coronary Artery Bypass Mechanical Valve Replacement Biological Valve Replacement Heart Transplant Joint Replacement, Knee (Right, Left, Bilateral) Joint Replacement, Hip (Right, Left, Bilateral) Joint Replacement within last 2 years Kidney Removed (Right, Left) Kidney Transplant Ovaries Removed: Endometriosis Ovaries Removed: Cyst Ovaries Removed: Ovarian Cancer Prostate Removed: Prostate Cancer Spleen Removed Hysterectomy: Fibroids Hysterectomy: Uterine Cancer None Other Please Specify*Skin Disease History* Acne Actinic Keratoses Asthma Basal Cell Skin Cancer Blistering Sunburns Dry Skin Eczema Flaking or Itchy Scalp Hay Fever/Allergies Melanoma Poison Ivy Precancerous Moles Psoriasis Squamous Cell Skin Cancer None Other Please Specify*Do you wear Sunscreen?*YesNoWhat SPF?Do you tan in a tanning salon?*YesNoDo you have a family history of Melanoma?*YesNoWhich relative(s)?Medications*Please enter all current medications you currently takeAllergies*Please enter all allergiesCigarette 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 OtherFamily Medical History(Only first degree relatives)Have you had a Pneumonia Vaccine*YesNoDate Date Format: MM slash DD slash YYYY Have you had a Flu Vaccine*YesNoDate Date Format: MM slash DD slash YYYY Preferred pharmacyName, Address, Phone, City or Zip code:Are you currently experiencing any of the following?Check any that applySymptom* None Problems with bleeding Problems with healing Problems with scarring Rash Sun sensitivity Immunosuppression Hay fever Fevers or chills Night sweats Unintentional weight loss Thyroid problems Abdominal pain/diarrhea Joint aches Muscle weakness Muscle aches Headaches Cough/shortness of breath Wheezing Anxiety Depression Other Other SymptomsAlerts* None Allergy to Adhesive Defibrillator Allergy to lidocaine MRSA Allergy to topical antibiotics Pacemaker Artificial heart valve Require antibiotics prior to surgical procedures Artificial joint replacement Rapid heart beat with epinephrine Blood Thinners or Blood Clots Are you pregnant or currently trying? Patient ConfirmationThe 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.