IMG_6060

Phone:
Fax:
E-mail:

501-907-7330
501-975-7457
lr2@arkansasdermatology.com

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  • Little Rock General Dermatology

    Address

    9601 Baptist Health Dr., Suite 1070
    Little Rock, AR 72205

New Patient Registration Form-Little Rock General Dermatology
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New Patient Registration Form








Primary Insurance








Secondary Insurance












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Dermatology Medical History-Little Rock General Dermatology
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DERMATOLOGY MEDICAL HISTORY



Has the lesion changed in color?
Does it bleed?
Does it itch?
Has it grown?
Does it scale or flake?
Is it painful?
Has the area been biopsied?
Has the area been previously treated?
Do you have a history of skin cancer?
Do you have a family history of skin cancer?
Do you have lupus?
Have you had an organ transplant?
Have you had a lot of sun exposure?

Please list all current medications and drug allergies in the area provided below. Please include all over the counter medicines, vitamins, and herbal therapies.




DERMATOLOGY REVIEW OF SYSTEMS

Heart failure
Stent Placement
Mitral Valve Prolapse
Artificial Heart Valve
High Blood Pressure
Rheumatic Fever
Stroke
Heart Attack
Bypass
Murmur
Pacemaker
Defibrillator
Angina Pectoris
Anemia
Emphysema
Tuberculosis
Allergies
Cough
Sinus Trouble
Dizziness
Headaches
Anxiety
Depression
Nervousness
Arthritis
Rheumatism
Artificial Joints
Glaucoma
Macular Degeneration
Cataracts
Indigestion
Ulcers
Reflux
Diabetes
Hepatitis
Thyroid Disease
HIV
Liver Disease
Staph Infection

SOCIAL HISTORY

 

Do you consume alcohol?
Do you consume caffeine?
Do you use tobacco?

 



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HIPAA Authorization Form-Little Rock General Dermatology
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HIPAA Authorization Form




I authorize Arkansas Dermatology to disclose my PHI (Protected Health Information) to the following providers and (or) facilities in regards to my treatment.





I authorize Arkansas Dermatology to disclose my PHI (Protected Health Information) to any person(s) indicated other than providers. This would include family, friends, guardian, POA...



If you do not authorize the release of your information leave the above blank and sign below.



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