New Patient Paperwork Last Name(Required)First Name(Required)MIDOB(Required) MM slash DD slash YYYY Sex(Required)MaleFemaleMarital Status(Required)MarriedSingleWidowedDivorcedLocal Address(Required)City(Required)State(Required)Zip(Required)Alternate AddressCityStateZIPPrimary Phone Number(Required)Alternate Phone NumberEmail(Required) Emergency Contact InformationNameRelationshipPhoneEmployerEmployer PhonePrimary Care PhysicianPhoneReferred byPhysicianInsuranceInternetFriendInsurance InformationInsurance(Required)Policy Number(Required)Group NumberGuarantor/SubscriberAddress(Required)DOB(Required) MM slash DD slash YYYY Preferred PharmacyCity(Required)Phone(Required)Preferred Language(Required) English SpanishOthers, please specifyNew Patient Medical HistoryName(Required)Date(Required) MM slash DD slash YYYY Please check all that apply for Medical History(Required) None Skin Cancer: BCC/SCC/Melanoma COPD Hypertension Seziures Anxiety Coronary Artery Disease High Cholesterol Previous Radiation Arthritis Depression Hypothyroidism Hyperthyroidism Atrial Fibrillation Diabetes Leukemia Solid Organ Transplant Stroke End Stage Renal Disease Lymphoma Bleeding Disorders Heart Attack GERD Lung Cancer Immunosuppression Bone Marrow Transplant Hearing Loss Lupus Pancreatitis Breast Cancer Hepatitis Prostate Cancer Colon Cancer HIV / AIDS BPHOthers, please specifyPlease check all that apply for Surgical History(Required) None Shoulder Joint Replacement Heart Stent Breast Surgery Artificial Heart Valve Other Joint Replacement Hysterectomy Hip Joint Replacement Abdominal Surgery Prostatectomy Knee Joint Replacement Heart Bypass SplenectomyOthers, please specifyPlease check all that apply for Skin Disease History(Required) None Actinic Keratoses Psoriasis Regular Sunscreen Use Basal Cell Carcinoma Atypical Moles Blistering Sunburns Squamous Cell Carcinoma Acne Tanning Bed Use Melanoma Eczema/Atopic Dermatitis Family History of Melanoma (1st Degree Relative)Others, please specifyDo you have any Medication Allergies? Yes NonePlease check any of the following that apply(Required) None Adhesive Allergy Lidocaine Allergy Topical Antibiotic Allergy Artificial Heart Valve Artificial Joint less than 2 years old Blood Thinners Defibrillator Pacemaker MRSA Premedication Prior to Procedures Rapid Heartbeat with Epinephrine Pregnant/Planning Pregnancy Breast Feeding Hepatitis HIV / AIDS DementiaOthers, please specifySmoking Status(Required) Current Smoker Former Smoker Never SmokedAlcohol Use(Required) Daily Occasionally NonePatient or Parent / POA Signature(Required)Date(Required) MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged.