New Patient Forms - Central Illinois Dermatology Page 2
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3CENTRAL ILLINOIS DERMATOLOGY, S.C.
Patient Medical Information
Patient Name: _______________________________________________________________
Allergies to Medication
_________________________________________
(oral and topical):
___________________________________________________________________________
Medications Presently Using
____________________________________
(oral and topical):
___________________________________________________________________________
If medications are prescribed by our physicians, do you prefer: Brand ____ Generic ____
Yes
No
Yes
No
Artificial Joints
_____ _____
Heart Disease
_____ _____
Kidney Disease
_____ _____
Diabetes
_____ _____
Stomach Disease
_____ _____
Liver Disease
_____ _____
Lung Disease
_____ _____
Mental Illness
_____ _____
Epilepsy
_____ _____
Excessive Bleeding
_____ _____
High Blood Pressure
_____ _____
Valvular Heart Disease
_____ _____
Unusual Scarring
_____ _____
Pregnant (currently)
_____ _____
Bacterial Endocarditis
_____ _____
Tubal ligation or
Cancer
_____ _____
Hysterectomy
_____ _____
Type ___________________________
Do you take aspirin
Do you take birth
or Advil daily?
_____ _____
Control pills
_____ _____
Do you have a
pacemaker?
_____ _____
Other_______________________________________________________________________
Do you give our office permission to discuss your medical information
with family members?
____YES
_____NO
If yes, please provide their name, phone number, and relationship below.
___________________________________________________________ ________________
Name
Phone
Relationship
___________________________________________________________ ________________
Name
Phone
Relationship
Patients’ signature:_____________________________________ Date:_________________
Payment Policy
Payment is expected at time of service, unless prior arrangements have been made. Insurance
companies vary in terms of reimbursement. We will be happy to give you an itemized statement
which will assist you in billing your insurance carrier. This office cannot accept responsibility for
collecting your insurance claim or for negotiating a settlement. You are responsible for payment
of all charges on your account within the limits of our credit policy.
I have read the above information concerning insurance and understand that I am responsible
for payment in full of all charges incurred during my treatment.
Signature: __________________________________ Date: _____________________
Patient (Parent or legal guardian)
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