FUCHS DERMATOLOGY REGISTRATION FORM NAME: LAST NAME FIRST NAME MIDDLE

ADDRESS: STREET UNIT

CITY STATE ZIPCODE SEX: MALE FEMALE

H PHONE: W PHONE: CELL PHONE: CALL IN EMERGENCY: @ PHONE: MARITAL STATUS: SINGLE MARRIED DIVORCED WIDOWED PARTNER

Date of Birth: email: @ SSN: EMPLOYEE STATUS: EMPLOYED NOT EMPLOYED RETIRED FULL TIME STUDENT PART-TIME EMPLOYER: DRUG ALLERGIES:

MEDICATIONS: REFERRING PHYSICIAN: REFERRED BY FAMILY/FRIEND: INITIAL APPOINTMENT DATE:

PLEASE CHECK ALL THAT APPLY: I WOULD LIKE THE OPPORTUNITY TO HAVE A TOTAL BODY EXAM TO DETECT ANY PRE-CANCEROUS OR MALIGNANT SKIN GROWTHS I AM INTERESTED IN PRODUCTS/TECHNIQUES AVAILABLE FOR PREVENTION AND/OR TREATMENT OF WRINKLES AND AGING SKIN LADIES: I AM EITHER PREGNANT, BREAST FEEDING OR MIGHT BECOME PREGNANT IN THE NEAR FUTURE GENTLEMEN: I AM INTERESTED IN PRODUCTS FOR MALE HAIR LOSS THIS OFFICE WILL SUBMIT TO THE FOLLOWING HEALTH INSURANCE CARRIERS: MEDICARE; CAREFIRST BLUE CROSS BLUE SHIELD; ANTHEM BLUE SHIELD OF VIRGINIA; AETNA AND TRICARE. IF YOU HAVE ANY OTHER INSURANCE CARRIER, YOU WILL BE EXPECTED TO PAY FOR YOUR VISIT AND SEEK REIMBURSEMENT FOR SERVICES RENDERED. PAYMENT IS EXPECTED AT THE TIME OF SERVICE FOR ANY COSMETIC SERVICE. IF YOU ARE NOT PREPARED TO PAY AT THE TIME OF SERVICE, PLEASE RESCHEDULE YOUR COSMETIC VISIT. THANK YOU. RESPONSIBLE PARTY: SAME AS PATIENT

RELATIONSHIP TO PATIENT: SPOUSE CHILD OTHER

BILLING ADDRESS: SAME AS PATIENT

DAYTIME PHONE:

PRIMARY INSURANCE COMPANY: PRINT YOUR NAME AS IT APPEARS ON INSURANCE CARD PLEASE:

EFFECTIVE DATE:

NAME OF SUBSCRIBER: SELF SPOUSE OTHER DOB: IDENTIFICATION # COPAY AMOUNT: $ GROUP# SECONDARY INSURANCE COMPANY: EFFECTIVE DATE: NAME OF SUBSCRIBER: SELF SPOUSE OTHER DOB: IDENTIFICATION # COPAY AMOUNT: $ GROUP# TERTIARY INSURANCE COMPANY: SUBSCRIBER: DOB: IDENTIFICATION # COPAY AMOUNT: $ GROUP#

PATIENT AUTHORIZATION I HEREBY AUTHORIZE GLENN H FUCHS, MD, PC TO APPLY FOR BENEFITS ON MY BEHALF FOR COVERED SERVICES RENDERED. I REQUEST PAYMENT FROM MY INSURANCE COMPANY BE MADE DIRECTLY TO THE ABOVE-NAMED PHYSICIAN. SIGNATURE OF SUBSCRIBER/BENEFICIARY DATE:

ACCOUNT NUMBER (OFFICE ASSIGNED)

COSMETIC PROCEDURES/PRODUCTS ARE NOT COVERED BY INSURANCE. BALANCES FOR THESE SERVICES ARE EXPECTED AT THE TIME OF SERVICE. PLEASE SCHEDULE YOUR ELECTIVE PROCEDURE ACCORDINGLY. IF YOU HAVE NOT SATISFIED YOUR DEDUCTIBLE (OUT OF POCKET EXPENSE) YOU WILL BE REQUIRED TO PAY 50% OF TODAYS CHARGES AT THE END OF YOUR VISIT. IF ADDITIONAL PAYMENT IS REQUIRED YOU WILL BE BILLED FOR THE BALANCE. THANK YOU.

FUCHS DERMATOLOGY PATIENT HISTORY FORM

Past Medical History [ ] Anxiety [ ] Arthritis [ ] Asthma [ ] Irregular heartbeat [ ] Bone Marrow transplant [ ] Breast Cancer [ ] COPD [ ] Depression [ ] Diabetes [ ] End Stage Renal Disease [ ] GERD (Gastric Reflux) [ ] Hay Fever/Allergies [ ] Hepatitis [ ] Hypertension [ ] Hyper/Hypothyroidism [ ] Leukemia [ ] Lung Cancer [ ] Lymphoma [ ] Prostate Cancer [ ] Seizures [ ] Stroke [ ] Other: ____________________ [ ] No Past Medical Problems

PAST SURGERIES [ ] Mastectomy [ ] Lumpectomy [ ] Heart valve replacement [ ] Heart Transplant [ ] Joint Replacement [ ] Skin: Biopsy [ ] Dysplastic Nevus Surgery [ ] Skin: Basal Cell Carcinoma [ ] Skin: Squamous Cell Carcinoma [ ] Skin: Melanoma [ ] Other: _________________

Skin Disease History [ ] Acne [ ] Actinic Keratoses (precancers) [ ] Basal Cell Carcinoma [ ] Blistering Sunburns [ ] Dry Skin [ ] Eczema [ ] Flaking or Itchy Scalp [ ] Melanoma [ ] Poison Ivy [ ] Precancerous Moles (Dysplastic Nevi) [ ] Psoriasis [ ] Squamous Cell Carcinoma [ ] Other: ____________________ [ ] No Past Skin Problems

Skin History Do you wear Sunscreen? [ ] Yes. What SPF # _______ [ ] No Do you tan in a salon? [ ] Yes [ ] No

Family History Is there a family history of melanoma? [ ] Yes. Which relative(s) _______________________________ _______________________________ [ ] No

Review of Systems: Have you recently experienced any of the following: [ ] Changing, bleeding or itching mole/lesion [ ] Rash [ ] Itching [ ] Burning Skin [ ] Depression [ ] Problems Healing [ ] Heat or Cold intolerance [ ] Hepatitis C [ ] Frequent nose bleeds

Alerts: Important info to know about you: [ ] Defibrillator [ ] Pacemaker [ ] Artificial Joint [ ] Artificial Heart Valve [ ] Antibiotic Prophylaxis [ ] History of Scarring (Keloid) [ ] History of passing out (Vasovagal) [ ] Organ Transplant Recipient [ ] Immunosuppressed (low immunity) [ ] Allergy to Adhesive [ ]Pregnant or Planning Pregnancy [ ] Breast Feeding [ ] Stomach Upset with Antibiotics [ ]Yeast infection with Antibiotics [ ] Allergy to topical antibiotics [ ] On blood thinners [ ] Allergic to lidocaine [ ] Rapid heartbeat with epinephrine [ ] HIV/AIDS [ ] Hepatitis C [ ] History of MRSA

GLENN H. FUCHS, M.D., P.C. AARON E. FUCHS, M.D.

ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES PATIENT CONSENT

Our NOTICE OF PRIVACY PRACTICES provides information about how we may use and disclose protected health information about your. The NOTICE contains a Patient Rights section describing your right under law. You have the right to review our NOTICE before SIGNING this consent. The terms of our NOTICE may change. If we change our notice, you may obtain a revised copy by contacting our office. You have the right to request that we restrict how protected health information for you is used or disclosed for treatment, payment and healthcare operations. By signing this form, you consent, to our use and disclosure of protected health information about you for treatment, payment and healthcare operations. You have the right to revoke this consent, IN WRITING, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on you prior consent. The Practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

• PROTECTED HEALTHCARE INFORMATION MAY BE DISCLOSED OR USED FOR TREATMENT, PAYMENT AND HEALTHCARE OPERATIONS.

• THE PRACTICE HAS A NOTICE OF PRIVACY PRACTICES AND THAT THE PATIENT HAS THE OPPORTUNITY TO REVIEW THIS NOTICE AND RECEIVE A COPY IF REQUESTED BY THE PATIENT OR THEIR REPRESENTATIVE.

• THE PATIENT RESERVES THE RIGHT TO CHANGE THE NOTICE OF PRIVACY POLICIES. • THE PATIENT HAS THE RIGHT TO RESTRICT THE USES OF THEIR INFORMATIONBUT THE DISCLOSURES WILL THEN

CEASE. • THE PRACTICE MAY CONDITION TRATMENT UPON THE EXECUTION OF THIS CONSENT. • THIS OFFICE MAY LEAVE A VOICE MESSAGE REGARDING SCHEDULED APPOINTMENTS ON ANSWERING SYSTEMS. • I HAVE SEEN THIS OFFICE’S NOTICE OF PRIVACY PRACTICES AND CONSENT TO ITS POLICIES.

This consent was signed by: ________________________Date: _______________________________________ (PRINT NAME OF PATIENT OR REPRESENTATIVE) SIGNATURE: _____________________________________________________________________________________________________

____________________________________________________________________________________ RELATIONSHIP TO PATIENT (IF OTHER THAN PATIENT) PATIENTS NAME (IF SIGNED BY A REPRESENTATIVE)

I GIVE PERMISSION TO RELEASE MY MEDICAL INFORMATION TO: (CHECK ALL THAT APPLY)

�NONE �SPOUSE �FAMILY �SPECIFIC PERSON(S) LISTED_______________________________________________________________________________

PLEASE ANSWER ALL QUESTIONS BELOW:

1. ADULTS 50-75 YEARS OF AGE: HAVE YOU HAD A COLONOSCOPY? � YES �NO �N/A

2. WOMEN AGES 40-69: HAVE YOU HAD A MAMMOGRAM TO SCREEN FOR BREAST CANCER �YES �NO �N/A

3. ADULTS 65 YEARS OR OLDER: HAVE YOU HAD A PNEUMONIA VACCINE? �YES �NO �N/A

4. SMOKING HISTORY: [ ]CURRENTLY SMOKES DAILY [ ]LIGHT TOBACCO USER [ ]FORMER SMOKER [ ] NEVER SMOKED