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24165 W IH 10, Suite 102
San Antonio, TX 78257

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24165 W IH 10, Suite 102
San Antonio, TX 78257

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Location

24165 W IH 10, Suite 102
San Antonio, TX 78257

210-698-6777 Schedule Now Pay Balance

Register/Forms

Health History

Name :

Date:

DRUG ALLERGY:

N

Y

LIST SURGERIES YOU HAD BEFORE

WHAT IS (ARE) THE REASON(S) FOR TODAY’S VISIT? PLS BE SPECIFIC

WHAT ARE THE AREAS THAT YOU WOULD LIKE US TO TREAT?

HAVE YOU SEEN A DERMATOLOGIST BEFORE? Name:

HAVE YOU EVER BEEN ON ACCUTANE (Isotretinoin, CLARAVIS) ?

Y

N

When?

DO YOU HAVE ANY HEALTH PROBLEM(S)?

Y

N

Explain:

WHAT ORAL/ TOPICAL MEDS DO YOU TAKE?

HAVE YOU EVER HAD A SKIN ALLERGY?

Y

N

Explain:

FRAGILE SKIN/ SKIN BURN EASILY?

Y

N

Explain:

HAVE YOU EVER HAD SKIN CANCER?

Y

N

Explain:

WHERE?

ANY FAMILY HISTORY OF SKIN CANCER?

Y

N

WHICH TYPE?

WHICH PART OF BODY?_

DO YOU FORM A THICK OR RAISED SCAR FROM A CUT OR BURN?

Y

N

Explain:

WHICH PART OF BODY

DO YOU FORM A THICK OR RAISED SCAR FROM A CUT OR BURN?

Y

N

Explain:

WHICH PART OF BODY

DO YOU TAKE VITAMINS/FISH OIL?

Y

N

DO YOU SMOKE?

Y

N

HOW MUCH?

DO YOU CONSUME ALCOHOL?

Y

N

HOW MUCH?

ARE YOU VEGETARIAN?

Y

N

DO YOU EAT HEALTHY?

Y

N

DO YOU EXERCISE?

Y

N

ACNE: DO YOU HAVE FREQUENT BREAKOUTS?

Y

N

SKIN CONDITION:

DRY

Y OILY COMBINATION

FLAKY

DO YOU EVER GET COLD SORES?

Y

N

HOW MUCH TIME DO YOU SPEND IN THE SUN?

A LOT

MODERATE

LITTLE

NONE

DO YOU WEAR SUNBLOCK?

Y

N

PLEASE ANSWER ALL THAT APPLY. IF ANY OF YOUR ANSWERS ARE YES, PLEASE BRIEFLY EXPLAIN ON THE LINE PROVIDED BELOW EACH SECTION.

RECENT WEIGHT CHANGES

NO

YES

RASH

NO

YES

GOOD APPETITE

NO

YES

FEVER

NO

YES

HEPATITIS

NO

YES

WEAKNESS

NO

YES

BREAST LUMPS

NO

YES

HIV

NO

YES

KELOID/SCAR

NO

YES

ACNE

NO

YES

SKIN LESIONS

NO

YES

CHANGE IN SIZE/SHAPE OF MOLES

NO

YES

SKIN CYST

NO

YES

ORAL LESIONS

NO

YES

HAIR LOSS/CHANGES

NO

YES

Field Name

Option1

Option2

NAIL LESIONS/CHANGES

NO

YES

PIGMENTED SPOTS

NO

YES

WHERE

EXPLAIN:

EXPLAIN:

WHERE IS THE MOLE?

EXPLAIN:

EXPLAIN:

EXPLANATION (IF ANSWERED YES):

SHORTNESS OF BREATH

NO

YES

NOSE BLEEDS

NO

YES

MOUTH SORES

NO

YES

BLEEDING GUMS

NO

YES

SORE THROAT

NO

YES

SWELLING FEET/ANKLES/HANDS

NO

YES

CHRONIC OR FREQUENT COUGHS

NO

YES

SPITTING UP FOOD

NO

YES

LIGHT HEADED OR DIZZY

NO

YES

HEADACHES

NO

YES

CONFUSION

NO

YES

NUMBNESS/TINGLING

NO

YES

WEAKNESS

NO

YES

DEPRESSION

NO

YES

INSOMNIA

NO

YES

HOT FLASHES

NO

YES

JOINT PAIN

NO

YES

MUSCLE PAIN OR CRAMPS

NO

YES

SLOW TO HEAL AFTER CUTS

NO

YES

PAST TRANSFUSION

NO

YES

ENLARGED GLANDS

NO

YES

BACK PAIN

NO

YES

EXPLANATION

SKIN OR OTHER ADVERSE REACTIONS TO:

PENICILLIN/ OTHER ANTIBIOTIC

NO

YES

LIDOCAINE OR OTHER ANESTHETICS

NO

YES

IODINE, METHIOLATE-OTHER ANTISEPTICS

NO

YES

ASPIRIN OR OTHER PAIN MEDICINE

NO

YES

OTHER DRUGS/MEDICATIONS.

NO

YES

EXPLANATION (IF ANSWERED YES):

HAVE YOU BEEN PREVIOUSLY DIAGNOSED WITH:

CANCER

NO

YES

RESPIRATORY DISEASE

NO

YES

INFLAMMATORY BOWEL DISEASE

NO

YES

CROHN’S DISEASE

NO

YES

HEART DISEASE

NO

YES

THYROID OR DIABETES

NO

YES

BLOOD DISORDER

NO

YES

KIDNEY DISEASE

NO

YES

ALLERGIES

NO

YES

PSYCHIATRIC DISORDER

NO

YES

LUPUS OR OTHER AUTOIMMUNE DISEASE

NO

YES

EXPLANATION:

Signature:

Registration

Cell Phone

Prefered Method of Sending Reminders

Occupation

Primary Insurance Company Name

Subscriber's Name

DOB:

Policy/ID Number:

Relation:

Secondary Insurance Company Name

Name

Field Name

Last

First

MI

Maiden Name:

Sex

Date

Mailing Address

Street

Apt #

City

State

Zip

Date of Birth

Marital Status

Email:

Work Phone

Home Phone

Employer (If Minor or if in College, Name of School)

Employer Phone Number ( )

How did you hear about us?

Google

Yahoo

Bing

Yellow Pages

Magazine

Sign Billboard

Radio

TV

Yelp

Family

Friend

Doctor

Other

Responsible Party for Payment (if different from patient) Name

Date of Birth

Address

Street

Apt #

City

State

Field Name

Occupation

Employer

Employer Phone Number

Address

How much is your specialist copay?

Do you have health saving account (HSA)?

Y

N

How much is your deductible?

Have you met your deductible?

Y

N

Group Number:

Patient Relationship to Insured:

Referred by a Physician?

Y

N

Name:

Specialty:

Pharmacy of Choice:

Pharmacy Street Number:

In case of Emergency Notify:

Subscriber’s Name

DOB:

Policy/ID Number:

Group Number:

Patient Relationship to Insured:

Phone:

Primary Care Physician(PCP):

Pharmacy Phone:

Phone:

PAYMENT POLICY I hereby confirm under penalty by law that all information on this page is true, correct and accurate. I authorize the release of medical information for the use of my primary care/ referring physician, consultants to process insurance claims, billing, insurance applications, & prescriptions. I understand that payment is required for all services at the time of visit. It is my responsibility to ensure my insurance covers my visits, I am responsible to obtain any referral that is needed for this specialist visit if I have a HMO. I authorize payment of medical benefits from insurance companies to Texas Institute of Dermatology, Laser & cosmetic surgery (TXID) and/or the physician. Applicable copayments and deductibles will be collected when services are rendered or there will be a $11.00 charge to offset administrative and mailing expenses if there is an outstanding balance after processing the insurance payment (this fee is waived if I authorize credit card payment for my balance). I understand that I am obligated to pay my balance within 30 days of service and authorize TXID to save my credit card information and automatically charge my credit card in file to pay any remaining balance. If any balance is unpaid after 30 days, I am subject to a 18% interest fee (minimum $20) for any outstanding balance after 30 days of service and additional $11 administrative fee for sending me the statement. It is my responsibility to inform TXID of any change in address, health insurance company. In the event my account is turned over to collections per this debtor contract, I understand that an additional collection fee (up to an additional 50%) will be added to my debt balance. I agree to pay an additional $50 fee for any returned check(s). I understand that for appointments which are missed or cancelled less than 72 hours prior to the scheduled appointment for any reason, I will incur a $45.00 missed appointment fee, which will be added to my account and I agree to pay it. I authorize Texas Institute of Dermatology (TXID) and his assignee to keep my signature and credit card info on file and to charge my card for any outstanding balance and charges not paid by insurance or by myself after 30 days from the date of service. I understand that this form is valid for future balances I may incur unless I cancel the authorization through a written notice to TXID. I understand that I have option to opt out the credit card authorization. In that case I agree with paying late fees and interest charge if I fail to pay the balance after 30 days of sending a statement. My signature below signifies my understanding and willingness to comply with this policy, collection fee. I understand that Texas Institute of Dermatology, Laser and Cosmetic Surgery does not currently accept Medicaid or Medicare, therefore I cannot send any invoice or request of payment or submission of my visit’s claim to Medicaid or Medicare. All medical, cosmetic services, skin care and cosmetic products are non-refundable.

PRINT YOUR NAME:

DATE:

SIGNATURE:

LEGAL GUARDIAN OR PERSON WHO IS FINANCIALLY RESPONSIBLE

DOB:

SIGNATURE:

Our Locations

Texas Institute of Dermatology, Leon Springs Dermatology Clinic

24165 IH-10 West, Suite 102 San Antonio, TX 78257

Texas Institute of Dermatology, Stone OAK Dermatology Clinic TXID2 Clinic 238 N Loop 1604, Suite 208 San Antonio, TX 78232

Copyright 2009-2024. Texas Institute of Dermatology, Laser and Cosmetic Surgery 24165 E IH 10, Suite 102, San Antonio, TX 78257.TM
All rights reserved, no parts of this website can be copied or reproduced without prior written approval.

Texas Institute of Dermatology © 2024

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