Phone:
Fax:
E-mail:

501-268-1500
501-268-1505
searcy@arkansasdermatology.com




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  • Searcy

    Address

    1604 E. Moore Ave.
    Searcy, AR 72143

New Patient Registration Form-Searcy
* required field

New Patient Registration Form








Primary Insurance








Secondary Insurance












Security Measure
Dermatology Medical History-Searcy Location
* required field

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?

 



Security Measure
HIPAA Authorization Form-Searcy Location
* required field

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.



Security Measure