TENNESSEE RIVER DERMATOLOGY 2471 Helton Drive Florence, AL 35630 256.765.2000 www.tennriverderm.com Thank you for choosing Tennessee River Dermatology. Enclosed please find the required forms for our new patients and our patients who have not been to our office within the last three (3) years. Please complete all forms and bring them with you on the day of your visit. Please also remember to bring your insurance card(s) and a picture ID for the patient. Copayments and deductibles are due the day of your visit. Please refrain from wearing scented products on the day of your visit. Dr. Hanson is extremely allergic to these. We ask that anyone who enters an exam room is not wearing perfume, cologne, body sprays or scented lotions. Thank you for your cooperation in this matter.

You will receive an automated reminder call a few days before your appointment requesting you to confirm or cancel your scheduled visit. If you are unable to keep your appointment kindly cancel using this reminder system or call our office at (256)765-2000 at least 24 hours prior to your appointment and we’ll be happy to reschedule at a time that is more convenient for you. Once again we thank you for choosing Tennessee River Dermatology and we look forward to providing you with a pleasant office visit. Sincerely, The Physicians and Staff Tennessee River Dermatology, P.C.

Tennessee River Dermatology Patient Name:New Patient Information Form

Date of Birth:

Preferred Pharmacy Name: City or Zip Code:

Past Medical History - Do you currently have any of the following medical conditions?Anxiety Depression HypothyroidismArthritis Diabetes LeukemiaAsthma End Stage Renal Disease Lung CancerAtrial Fibrillation GERD Lymphoma

Bone Marrow Transplant Hearing Loss Prostate CancerBPH Hepatitis Radiation TreatmentBreast Cancer Hypertension SeizuresColon Cancer HIV / AIDS StrokeCOPD Hypercholesterolemia NONE OR OTHER:Coronary Artery Disease Hyperthyroidism

Past Surgical History - Have you had a procedure or surgery on any of the following organs?Appendix Joint Replacement: Knee __L __R Prostate: TURPBladder (Cystectomy) Kidney: Kidney Biopsy Rectum: APRBreast: Biopsy __L __R Kidney: Stone Removal Rectum: ResectionBreast: Lumpectomy __L __R Kidney: Transplant Skin: Basal Cell CarcinomaBreast: Mastectomy __L __R Kidney: Nephrectomy Skin: MelanomaColon Cancer Resection Liver: Hepatectomy Year: __________ Dr. __________________Colon: Diverticulitis Liver: Liver Transplant Location: _____________________________Colon: IBD Liver: Shunt Skin: Skin BiopsyColon: Colostomy Bag Ovaries: Endometriosis Skin: Squamous Cell CarcinomaGallbladder Ovaries: Ovarian Cancer Spleen (Splenectomy)Heart: Bypass Surgery Ovaries: Ovarian Cyst Testicles (Orchiectomy)Heart: Heart Transplant Ovaries: Tubal Ligation Uterus: FibroidsHeart: Valve Replacement Pancreas: Pancreatectomy Uterus: Uterine CancerHeart: PTCA Prostate: Biopsy Uterus: Cervical CancerJoint Replacement: Hip __L __R Prostate: Cancer NONE OR OTHER:

Skin Disease History - Have you had any of the following skin conditions:Acne Dry Skin Poison IvyActinic Keratosis Eczema Precancerous MolesAsthma Flaking or Itchy Scalp PsoriasisBasal Cell Skin Cancer Hay Fever / Allergies Squamous Cell Skin CancerBlistering Sunburns Melanoma NONE OR OTHER:

Year: __________ Dr. __________________ Location: _____________________________

Updated 02.16.2018

Tennessee River Dermatology Patient Name:New Patient Information Form

Date of Birth:

Primary Care Physician: Referring Physician: Patient Email Address:

Do you tan in a tanning salon? No Yes Any family history of melanoma? No Yes

Do you wear Sunscreen? No Yes Blood Relative:

If yes, SPF: Blood Relative:

Medications - Please list all current medications:

1. 2.

4. 5. 6.

Allergies - Please list all allergies and reactions if known:

1. 2. 3.

Smoking Status (please choose one):Current, every day Never smoked Start Smoking (mm/dd/yy):Current, some days Unknown if ever smoked Quit Smoking (mm/dd/yy):Former smoker Number of Packs Per Day: Total Years:

Alcohol Intake (please choose one):How many times in the past year have you had 5 or more drinks in a day for men, or 4 or more drinks in a day for women or any adult older than 65? 0 1 2

Vaccinations and Immunizations:

Have you received a flu vaccination this season? No Yes Month/Year Rec'd:

Have you been vaccinated for Pneumonia? No Yes Month/Year Rec'd:

Occupation and Workplace:

Place of Residence:

How long?

Updated 07.12.17

Tennessee River Dermatology Patient Name:New Patient Information Form

Date of Birth:

Review of Systems - Please indicate whether or not you are experiencing any of the following conditions:Yes No

problems with bleeding ○ ○problems with healing ○ ○problems with scarring ○ ○rash ○ ○immunosuppression ○ ○hay fever ○ ○chest pain ○ ○fever or chills ○ ○night sweats ○ ○unintentional weight loss ○ ○thyroid problems ○ ○sore throat ○ ○blurry vision ○ ○abdominal pain ○ ○bloody stool ○ ○bloody urine ○ ○joint aches ○ ○muscle weakness ○ ○neck stiffness ○ ○headaches ○ ○seizures ○ ○cough ○ ○shortness of breath ○ ○wheezing ○ ○anxiety ○ ○depression ○ ○Other: ○ ○

Alerts - Please indicate whether or not any of the following conditions apply to you:Yes No

allergy to adhesive ○ ○allergy to lidocaine ○ ○allergy to topical antibiotics ○ ○artificial heart valve ○ ○artificial joints within the past two years ○ ○blood thinners ○ ○defibrillator ○ ○MRSA ○ ○pacemaker ○ ○premedication prior to procedures ○ ○rapid heart beat with epinephrine ○ ○pregnancy or planning a pregnancy ○ ○West Africa: Travel or Contact ○ ○Ebola Exposure ○ ○

Tennessee River Dermatology

Page 1 of 2  

NOTICE OF PRIVACY PRACTICES

This notice describes how medical information about you may be used and disclosed and how you can gain access to this information. Please review it carefully.

USES AND DISCLOSURES

Treatment: Your health information may be used by staff members or disclosed to other health care Professionals for the purpose of evaluating your health, diagnosing medical conditions, and providing Treatment. For example, results of laboratory tests and procedures will be available in your medical record to all health professionals who may provide treatment or who may be consulted by staff members.

Payment: Your health information may be used to seek payment from your health plan, from other sources of coverage such as an automobile insurer, or from credit card companies that you may use to pay for services. For example, your health plan may request and receive information on dates of service, the services provided, and the medical condition being treated.

Health Care Operations: Your health information may be used as necessary to support the day-to-day activities and management of Tennessee River Dermatology. For example, information on the services you received may be used to support budgeting and financial reporting, and activities to evaluate and promote quality.

Law Enforcement: Your health information may be disclosed to law enforcement agencies, without your permission, to support government audits and inspections, to facilitate law-enforcement investigations, and to comply with government mandating reporting.

Public Health Reporting: Your health information may be discussed to public health agencies as required by law. For example, we are required to report certain communicable diseases to the state’s public health department.

Appointment reminders: Your health information will be used by our staff to send you appointment reminders.

Information about treatments: Your health information may be used to send you information on the treatment and management of your medical condition that you may find to be of interest. We may also send you information describing other health-related goods and service that we believe may interest you.

Other Uses and Disclosures Require Your Authorization: Disclosure of your health information or its use for any purpose other than those listed above requires your specific written authorization. If you change your mind after authorizing use of disclosure of your information you may submit a written revocation of the authorization. However, your decision to revoke the authorization will not affect or undo any use or disclosure of information that occurred before you notified us of your decision.

Tennessee River Dermatology

Page 2 of 2  

NOTICE OF PRIVACY PRACTICES

INDIVIDUAL RIGHTS

You have certain rights under the federal privacy standards including:

The right to request restrictions on the use and disclosure of your protected health information

The right to receive confidential communication concerning your medical condition and treatment

The right to inspect and copy your protected health information

The right to receive an accounting of how and to whom your PHI has been disclosed

The right to receive a printed copy of this notice

TENNESSEE RIVER DERMATOLOGY’S DUTIES: We are required by law to maintain the privacy of your protected health information and to provide you with this notice of privacy practices. We also are required to abide by the privacy policies and practices that are outlined in this notice.

RIGHT TO REVISE PRIVACY PRACTICES As permitted by law, we reserve the right to amend or modify our privacy policies and practices. These changes in our policies and practices may be required by changes in federal and state laws and regulations. Whatever the reason for these revisions, we will provide you with a revised notice on your next office visit. The revised policies and practices will be applied to all protected health information that we maintain.

REQUEST TO INSPECT PROTECTED HEALTH INFORMATION As permitted by federal regulation, we require that request to inspect or copy protected health information be submitted in writing. You may obtain a form to request access to your records contacting Receptionist or Privacy Official.

COMPLAINTS If you would like to submit a comment or complaint about our privacy practices, you can do so by sending a letter outlining your concerns to: Privacy Official, Tennessee River Dermatology, 2471 Helton Drive, Florence, Alabama 35630

Effective Date: This notice is effective April 16, 2003

TENNESSEE RIVER DERMATOLOGY 2471 HELTON DRIVE FLORENCE, AL 35630

256.765.2000 www.tennriverderm.com

Follow major roadways to Florence: From North (Hwy 43): Continue South until Hwy 43 merges into Hwy 72. Head toward Florence. Follow directions from East (below). From East (Hwy 72, Hwy 43): Continue west through the Cox Creek Parkway intersection to Florence Blvd. Proceed 2.2 miles and turn right (North) onto 17/157 towards Waynesboro (becomes Helton Drive). Clinic is located 1.8 miles on the left side of the road. From Southeast (Alt Hwy 72, Hwy 157): Turn North (right) on 133 and proceed 7.5 miles to Helton Drive. (Do not take the 133 exit ramp). Clinic is 3.2 miles on the left side of the road. From South/Southwest (Hwy 43): Continue North to Avalon Ave in Muscle Shoals and turn East (right). Proceed 1.8 miles then turn North (left) on SE Wilson Dam Road/AL 133. Proceed to Helton Drive. (Do not take the 133 exit ramp) Clinic is 3.2 miles on the left hand side of the road.

133

DIRECTIONS TO TENNESSEE RIVER DERMATOLOGY