Patient Information THIS SECTION MUST BE COMPLETED FOR ALL PATIENTS: Date / /

Name: Last First M.I.

Mailing Address: City State Zip

Home Phone: ( ) Cell Phone: ( )

Work Phone: ( ) E-mail:

Primary Care Physician: Referring Physician:

Date of Birth: / / Sex: Male Female Social Security #

Marital Status: Married Single Widowed Other

Employment Status: Working PT Working FT Unemployed Student PT Student FT

Disabled Retired

Race: White Hispanic African American

Asian Other

Employer Name:

Language: English Spanish

Other

Phone:

Emergency Contact Relationship Emergency Phone #

RESPONSIBLE PARTY INFORMATION (if different from patient) RELATIONSHIP

Name: Last First M.I.

Date of Birth: / / /

Mailing Address

Home Phone: ( )

City State Zip

Work Phone: ( )

How did you hear about our practice? Yellow Pages Newspaper Friend/Patient Magazine Social Media Revive Medical Spa, LLC Physician Other

INSURANCE INFO: Do you have health insurance? Yes No Guarantor is the person whose NAME is on the insurance card.

Primary Insurance Company: Secondary Insurance Company:

Insurance ID Number: Insurance ID Number:

Insurance Group Number: Insurance Group Number:

Name of Guarantor: Name of Guarantor:

Relationship to Patient: Relationship to Patient:

Guarantor Social Security Number: Guarantor Social Security Number:

Guarantor Date of Birth: Guarantor Date of Birth:

Pharmacy of Choice: Name Address

Please present your insurance card(s) and a photo ID to the receptionist along with this completed form.

1444 E. Stearns St., Suite 11 • Fayetteville, AR 72703

701 NW McNelly Rd • Bentonville, AR 72712

1320 Hwy 62/65 N• Harrison, AR 72601

Toll Free Phone 1.855.400.9884 • Toll Free Fax 1.833.653.8044

Medical History Name: Date: / /

Date of Birth What is the reason for your visit today? PAST MEDICAL HISTORY — PLEASE CHECK ALL THAT APPLY

☐ Anxiety☐ Arthritis☐ Artificial Joints☐ Asthma☐ Atrial fibrillation☐ BPH☐ Bone marrow transplant☐ Breast cancer☐ Colon cancer☐ COPD☐ Coronary artery disease

☐ Depression☐ Diabetes☐ End stage renal disease☐ GERD☐ Hearing loss☐ Heart attack☐ Hepatitis☐ Hypertension☐ HIV/AIDS☐ Hypercholesterolemia☐ Hyperthyroidism

☐ Hypothyroidism☐ Leukemia☐ Lung cancer☐ Lymphoma☐ Pacemaker☐ Prostate cancer☐ Radiation treatment☐ Seizures☐ Stroke☐ Other ______________________

PAST SURGICAL HISTORY: PLEASE CHECK ALL THAT APPLY ☐ Appendix removed☐ Bladder removed☐ Mastectomy (Right, left, both)☐ Lumpectomy (Right, left, both)☐ Breast Biopsy (Right, left, both)☐ Breast reduction☐ Breast implants☐ Colectomy: Colon cancer resection☐ Colectomy: Diverticulitis☐ Colectomy: IBD☐ Gallbladder removed☐ Coronary artery bypass☐ PTCA / stents☐ Mechanical valve replacement

☐ Biological valve replacement☐ Heart transplant☐ Joint replacement knee

right, left, both ☐ Joint replacement hip, right, left, both☐ Joint replacement within last 2 years☐ Kidney biopsy/transplant☐ Kidney removed (right/left)☐ Kidney stone removal☐ Ovaries removed: endometriosis☐ Ovaries removed: cyst☐ Ovaries removed: ovarian cancer☐ Prostate removed: prostate cancer☐ Prostate biopsy

☐ TURP☐ Skin biopsy☐ Liver transplant☐ Basal cell cancer surgery☐ Squamous cell cancer surgery☐ Melanoma surgery☐ Spleen removed☐ Testicles removed (right, left, both)☐ Hysterectomy: fibroids☐ Hysterectomy: uterine cancer☐ None☐ Other_________________________

SKIN DISEASE HISTORY: PLEASE CHECK ALL THAT APPLY ☐ Acne ☐ Flaking or itchy scalp ☐ Squamous cell skin cancer☐ Actinic keratoses ☐ Hay fever/allergies ☐ Psoriasis☐ Asthma ☐ Melanoma ☐ Eczema☐ Basal cell carcinoma ☐ Poison ivy ☐ Dry skin☐ Blistering sunburns ☐ Precancerous mole ☐ Other__________________________

Family history of melanoma Yes No If yes, which member_______________________ Family history of skin cancer Yes No

Female Patients: Are you currently pregnant? Yes No Date of Last Menstrual Cycle: ____________

Do you smoke? Former smoker Never smoked?

☐ Yes☐ Yes☐ Yes

☐ No ☐ No ☐ No

Family medical history and person’s Illicit drug use ☐ Yes ☐ No relationship to you?

Currently or have had MRSA Received flu shot this year

☐ Yes☐ Yes

☐ No☐ No

Alcohol use □ None ☐ Less than one drink per day ☐ 1-2/day □ 3+/day

CURRENT MEDICATIONS: Names (include OTC, herbal, vitamins)1. 2. 3. 4. 5.

DRUG ALLERGIES: Names, Reaction (rash, hives, nausea, etc.)1. 2. 3. 4. 5.

REVIEW OF SYSTEMS ☐ Abdominal pain ☐ Thyroid ☐ Difficulty hearing ☐ Joint swelling☐ Angina ☐ Osteoporosis ☐ Depression ☐ Loss of consciousness☐ Prolonged bleeding ☐ Defibrillator/Pacemaker ☐ Diarrhea ☐ Muscle pains☐ Skin growths ☐ Ambulate with cane ☐ Difficult sleeping ☐ Night sweats☐ Shortness of breath ☐ Abnormal wound healing ☐ Ear pain ☐ Numbness☐ Seizures ☐ Bloody bowel movement ☐ Fevers ☐ Nausea☐ Vomiting ☐ Chills ☐ Fainting ☐ Painful urination☐ Weight loss (unintentional) ☐ Chest pain ☐ Headache ☐ Painful bowel movement☐ Ulcers ☐ Change in vision ☐ Heart palpitation ☐ Paralysis☐ Arthritis ☐ Chronic rash ☐ Indigestion/reflux ☐ Glaucoma☐ Diabetes ☐ Cough ☐ Incontinence ☐ Double vision☐ Hypertension ☐ Dizziness/fainting ☐ Inability to urinate ☐ Joint pains

� · '-:: ADVANCED DERMATOLOGY ·\ .... :�: & SKIN CANCER CENTER, PLLC

Patient Financial Policy

Disability Claims, Leave of Absence {FLMA), Cancer Claims and other forms you might request our office to

complete to you:

We now require a $25.00 (per set) pre-payment to complete these forms.

Pathology:

If you have a biopsy and require pathology reporting, please understand the pathology charges are billed

after the pathology report is received and a diagnosis has been made. You will be billed for the pathology

charges at a later date. This bill may be from our office and/or an outside pathology department,

depending on your diagnosis.

Products:

All products are to be paid for at date of purchase. We do not send statements for products. All product

sales are final; no returns or exchanges are allowed.

Cosmetic Procedures:

Cosmetic procedures are to be paid for on the date of service. Some procedures may require pre-payment

or deposit with the balance paid on date of service. There will be a $100.00 charge for all cosmetic

appointments that are not canceled at least 24 hours prior to the set appointment time by calling our office at

(479) 718-7546 and speaking with one of our staff or leaving a voice message.

Methods of Payment:

Our office accepts; personal checks, cash, MasterCard, Visa, Discover, CareCredit and debit cards.

There is a $25.00 charge to the patient for returned checks due to insufficient funds or closed accounts.

Cancellation/No-Show Policy:

Our office makes attempts to confirm your appointment prior to the scheduled date. Please provide our

office a minimum of 24 hours' notice if you are unable to keep your appointment. Our staff personally

contacts every surgery patient to confirm your appointment. There will be a $100.00 charge if you fail to keep

the surgery appointment without a 24-hour prior notification.

Please be aware your insurance does not cover the charge for no-show visits-regardless of your insurance, you

are fully responsible for these charges. The charge will need to be paid prior to rescheduling the

appointment or surgery.

Collection Charges:

In the event you have a delinquent balance on your account and after making all possible attempts to

collect the amount, if the account is turned over to an outside collection agency, you will be responsible for the

balance on the account plus any fees the collection agency charges for collection, which could be up to

33% of the balanced owed.

Questions:

Should you have any questions regarding our financial policies, please contact the office at (479) 718-7546.

You may reach Billing by choosing option 3 or extension 517.

PFP 20190508