New Patient | Moore Dermatology

Patient Name

First

Middle

Last

Gender

Male

Female

Date of Birth (mm/dd/yyyy)

Marital Status

Address

City

State

Zip Code

Home Phone (xxx-xxx-xxxx)

Cell Phone (xxx-xxx-xxxx)

Email

Referred By

Primary Care Physician

Do you have a primary care physician?

Yes

No

Pharmacy Information

Do you have a preferred pharmacy?

Yes

No

Employer Information

Employer

Occupation

Employer Phone (xxx-xxx-xxxx)

Emergency Contact Information

First Name

Last Name

Emergency Contact Phone (xxx-xxx-xxxx)

Relationship to Patient

Insurance Information

Insurance Company

Medical History

What brings you to the office?

Please describe any previous skin conditions that you have experienced

Current Medications

Drug Allergies

Please check all that Apply

Currently on medication

Currently on blood thinners

Allergic to any medications

Have had a biopsy for a suspicious growth

Have visited tanning salons and/or do you sunbathe

Have had skin cancer

Interested in information about cosmetic procedure

N/A

Have you been hospitalized and/or had surgery?

Yes

No

Preferred Date of Your Appointment

You will be contacted within 48 hours to confirm your exact appointment time & day.