New Patient Intake Form - Z-ROC Dermatology

PATIENT INTAKE FORM

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Legal Name:*

(First) Middle Initial (Last) (Prefer to be called)

Date of Birth:*

Age:*

Sex:*

Marital Status:*

Mailing Address:*

Street Address City State / Province / Region ZIP / Postal Code

Home Phone:

OK to leave message*

OK to leave message

Cell Phone:*

Mobile Carrier:*

Occupation:*

Work Phone:*

Ext:*

OK to leave message*

OK to leave message

Email Address:*

Emergency Contact:*

Relationship:*

Phone #:*

Primary Care Physician and Clinic Name:*

Primary Language:*

English

Spanish

Somali

Other:

Other:*

Race:*

Caucasian

Asian

African American

Other:

Prefer not to Say

Other:*

Ethnicity:*

Hispanic

Latino

Not Hispanic or Latino

Prefer not to Say

Responsible Party (if different from patient)

Yes

Legal Name:*

(First) Middle Initial (Last)

Date of Birth:*

Relationship to Patient:

Address:*

Street Address City State / Province / Region ZIP / Postal Code

Home Phone:*

Cell Phone:*

Work Phone:

Ext:*

Pharmacy Information (What is your primary choice)

Pharmacy Name:*

Address

Street Address City State / Province / Region ZIP / Postal Code

Phone:*

Have you had or currently have any of the following medical conditions:

Other:*

Are you currently:

Pregnant*

Yes

Planning Pregnancy:*

Yes

Breast Feeding:*

Yes

Have you had any surgeries? (Including joint replacement and heart valve surgeries):

Medications: (including over-the-counter)

Drug Allergies:

Do you have or have had any of the following skin conditions?

Other:*

Do you have a family history of melanoma or other skin cancers?*

Yes

Unknown

Unknown:*

If yes, which relative? What type of skin cancer?*

Do you tan at a salon?

Yes

Do you wear sunscreen?

Yes

What SPF?

Smoking Status:*

Current Everyday Smoker

Current Some Day Smoker

Former Smoker

Never Smoked

Smokeless Tobacco Vape

Alcohol Consumption:*

None

Less Than 1 Drink Per Day

1-2 Drinks Per Day

3 or More Drinks Per Day

CONSENT TO COMMUNICATIONS

Patient’s Name (please print)*

Patient’s Date of Birth*

Please check all that apply:

Untitled

I authorize Z-Roc Dermatology, LLC. (“Z-Roc Dermatology”) to deliver my detailed health information, including but not limited to my detailed biopsy results, to me via the following methods:

Voicemail:

Untitled

I authorize Z-Roc Dermatology to release my detailed health information, including but not limited to my detailed biopsy results, and to discuss this information with the following individual(s):

Name

Relationship to patient

Name

Relationship to patient

Please provide an alternate contact, listed person(s) will only be contacted by Z-Roc Dermatology, LLC. (“Z-Roc Dermatology”) in the event of an Emergency or if we are urgently needing to contact you.

Alternate Contact Name (please print)*

Relationship to patient*

Telephone Number:*

Untitled*

Okay to leave voicemail

Untitled*

I would like Z-Roc Dermatology’s Cosmetic Specials and Newsletter emailed to me at the following

Email Address:*

I acknowledge Z-Roc Dermatology will confirm appointments by automated text message, phone calls and email. These reminders will be sent to the phone number and email address provided at intake. If I wish to discontinue these reminders, I may do so by following the opt-out process contained within such messages or by notifying Z-Roc Dermatology at: (954) 564-0040

I have fully read, understand and agree to the information contained in this Consent to Communications (“Form”). I have had the chance to ask questions about the information contained in this Form, and all my questions have been answered to my satisfaction. I understand and agree that this Form will remain in effect until I revoke it by sending a written request to Z-Roc Dermatology’s Privacy Officer, which I may do at any time. I understand that any such revocation shall have no effect on any actions taken in reliance on this Form before to my revocation.

Patient’s Signature (or Patient Representative’s Signature)

Initial Here:*

If you are unable to sign using the patient signature, use this field to enter your initials.

Today’s Date:*

If patient is under the age 18 or unable to provide informed consent:

Representative’s Name (please print):*

Relationship to patient*

CONSENT AND AUTHORIZATION FORM

Consent and Authorization for the Release of Information

Release of Information

I consent to the release by Z-Roc Dermatology, LLC (“Z-Roc Dermatology”) of health records and information about me, to the extent permitted by law, to the following individuals and entities:

To a health care provider being advised of or consulted in connection with my treatment or care.
To a health plan, insurer, third-party payor, third party administrator or other organization providing me with health benefits, for the purposes of claims payment and benefit determinations, fraud investigations, or quality of care studies or reviews.
To a person or organization in connection with Z-Roc Dermatology’s health care operations. These operations may include, but are not limited to, interdisciplinary care conferences, quality improvement activities, performance evaluations, business management, and other related activities.
To a person or organization providing services in connection with Z-Roc Dermatology’s patient health record portal or the person or organization hosting or providing the portal service.
To a health information exchange where my information may be shared with and accessed by other health care providers and health care related entities for purposes of treatment, payment, and the health care operations of the participating organizations.
To the individuals that I included on my Consent to Communications from Z-Roc Dermatology form.

Record Locator and Patient Information Services. I consent to Z-Roc Dermatology searching for, accessing, and/or receiving health information about me and the location of my health records through a record locator service and/or patient information service.

Revocation. I understand and agree that this consent and authorization is valid until I revoke it, which I may do at any time by giving written notice to Z-Roc Dermatology. I further understand and agree that revocation will not apply to information that has already been disclosed pursuant to this Consent and Authorization Form.

Payment Responsibility and Authorization

Payment Responsibility

I agree that I am financially responsible and shall pay for all services furnished to me by Z-ROC Dermatology and any providers performing services on my behalf at the request of Z-Roc Dermatology including, but not limited to, charges that are not paid in full by my insurance, government program benefits or other third-party payors (each a “Third-Party Payor” and collectively, “Third-Party Payors”). I shall make these payments upon receipt of a statement. I understand and agree that Z-Roc Dermatology is not responsible for collecting payments from Third-Party Payors or negotiating disputed settlements on my behalf. I agree to pay or reimburse Z-Roc Dermatology for all costs it may incur in collecting amounts owed to it for the services provided to me, including, but not limited to, attorneys’ fees and collection agency fees.

Payment Authorization

I shall inform Z-Roc Dermatology of all Third-Party Payors through which I may have benefits covering the services provided to me by or on behalf of Z-Roc Dermatology. I authorize Z-Roc Dermatology to directly bill my Third-Party Payors for such services but acknowledge that Z-Roc Dermatology is not obligated to submit claims to a Third-Party Payor(s) on my behalf unless required by law or by its contract with a Third-Party Payor. I also authorize any Third-Party Payor through which I may have benefits to make payment directly to Z-Roc Dermatology for such services, and to release any medical information about me needed to determine the benefits payable for such services. If I have a Medicare Supplement Insurance (Medigap) policy, I request that payment of authorized Medigap benefits be made to Z-Roc Dermatology directly on my behalf by my Medigap insurer.

Payment of Medicare Benefits to Z-Roc Dermatology

I request payment of authorized Medicare benefits to be made either to me on my behalf to Z-Roc Dermatology for services furnished to me by Z-Roc Dermatology. I authorize any holder of medical information about me to release to the Centers for Medicare and Medicaid Services and its agents any information needed to determine these benefits or the benefits payable for related services.

Referrals and Prior Authorizations

I understand and agree that it is my responsibility to know and abide by the terms of my Third-Party Payor coverage, including referral or authorization requirements and other types of benefit limitation. I understand that I am responsible for obtaining any required referrals for specialized care before making appointments. I agree to obtain a required authorization for services or to provide all information needed by Z-Roc Dermatology to obtain a required authorization in advance of my visit. If my Third-Party Payor refuses to cover the services I receive, based on the lack of a required referral or authorization or otherwise, I understand I am financially responsible and agree that I will pay for the services provided by Z-Roc Dermatology, except to the extent such obligation is limited by applicable law or contractual obligations of Z-Roc Dermatology applicable to payment for those services.

Full Body Skin Cancer Screenings

I understand and agree that routine full body skin cancer screenings are not covered in full as a preventative service under most health plans, including Medicare. If my Third-Party Payor requires the payment of a copay for these screenings (e.g., as a specialist visit), I agree to pay this copay at the time of service. I further understand that Z-Roc Dermatology will send me an invoice for any coinsurance or deductible balances due, and I agree to timely pay the amount specified on this invoice.

Notice of Privacy Practices

Confidentiality

It is the policy of Z-Roc Dermatology to protect the privacy and confidentiality of my health information in compliance with applicable law.

Notice of Privacy Practices

Z-Roc Dermatology’s Notice of Privacy Practices explains how Z-Roc Dermatology may use and disclose my health information. It also explains my rights regarding this kind of information. Z-Roc Dermatology may revise its Notice of Privacy Practices at any time and will provide me with a copy of the revised Notice of Privacy Practices at my request. Z-Roc Dermatology’s Notice of Privacy Practices is available at each of its clinics and on its website (www.zrocderm.com).

Acknowledgment of Receipt. I acknowledge that I have received Z-Roc Dermatology’s Notice of Privacy Practices.

Consent for Treatment

I understand that I have the right to be informed of the nature and purpose of all services provided to me at Z-Roc Dermatology, as well as alternatives, risks, consequences, or complications of such services. I hereby authorize and consent to the examination, diagnosis, procedures, and treatments which my practitioner and I agree are appropriate. I understand that no guarantee has been made as to the results of the care, treatment, and/or medications given to me. This consent shall remain in effect until I choose to revoke it in writing.

Public Comments

Before publicly making or posting any negative or critical comments about Z-Roc Dermatology (e.g., on social media, the internet (including review sites), etc.), I agree to notify Z-Roc Dermatology of my concerns in writing and wait thirty (30) days before publicly making or posting any such comments, thus allowing Z-Roc Dermatology the opportunity to address my concerns.

I have fully read, understand, and agree to the information contained in this Consent and Authorization Form (“Form”). I have had the chance to ask questions about the information contained in this Form, and all my questions have been answered to my satisfaction. This Form will remain in effect until I revoke it by sending a written request to Z-Roc Dermatology’s Privacy Officer, which I may do at any time. I understand that any such revocation shall have no effect on any actions taken in reliance on this Form before my revocation.

I. CONSENT AND AUTHORIZATION FOR THE RELEASE OF INFORMATION.

a. Release of Information. I consent to the release by Z-Roc Dermatology, LLC (“Z-Roc Dermatology”) of health records and information about me, to the extent permitted by law, to the following individuals and entities:

To a health care provider being advised of or consulted in connection with my treatment or care.
To a health plan, insurer, third-party payor, third party administrator or other organization providing me with health benefits, for the purposes of claims payment and benefit determinations, fraud investigations, or quality of care studies or reviews.
To a person or organization in connection with Z-Roc Dermatology’s health care operations. These operations may include, but are not limited to, interdisciplinary care conferences, quality improvement activities, performance evaluations, business management, and other related activities.
To a person or organization providing services in connection with Z-Roc Dermatology’s patient health record portal or the person or organization hosting or providing the portal service.
To a health information exchange where my information may be shared with and accessed by other health care providers and health care related entities for purposes of treatment, payment, and the health care operations of the participating organizations.
To the individuals that I included on my Consent to Communications from Z-Roc Dermatology form.

b. Record Locator and Patient Information Services. I consent to Z-Roc Dermatology searching for, accessing, and/or receiving health information about me and the location of my health records through a record locator service and/or patient information service.

c. Revocation. I understand and agree that this consent and authorization is valid until I revoke it, which I may do at any time by giving written notice to Z-Roc Dermatology. I further understand and agree that revocation will not apply to information that has already been disclosed pursuant to this Consent and Authorization Form.

II. PAYMENT RESPONSIBILITY AND AUTHORIZATION.

a. Payment Responsibility. I agree that I am financially responsible and shall pay for all services furnished to me by Z-ROC Dermatology and any providers performing services on my behalf at the request of Z-Roc Dermatology including, but not limited to, charges that are not paid in full by my insurance, government program benefits or other third-party payors (each a “Third-Party Payor” and collectively, “Third-Party Payors”). I shall make these payments upon receipt of a statement.

I understand and agree that Z-Roc Dermatology is not responsible for collecting payments from Third-Party Payors or negotiating disputed settlements on my behalf. I agree to pay or reimburse Z-Roc Dermatology for all costs it may incur in collecting amounts owed to it for the services provided to me, including, but not limited to, attorneys’ fees and collection agency fees.

b. Payment Authorization. I shall inform Z-Roc Dermatology of all Third-Party Payors through which I may have benefits covering the services provided to me by or on behalf of Z-Roc Dermatology. I authorize Z-Roc Dermatology to directly bill my Third-Party Payors for such services but acknowledge that Z-Roc Dermatology is not obligated to submit claims to a Third-Party Payor(s) on my behalf unless required by law or by its contract with a Third-Party Payor.

I also authorize any Third-Party Payor through which I may have benefits to make payment directly to Z-Roc Dermatology for such services, and to release any medical information about me needed to determine the benefits payable for such services. If I have a Medicare Supplement Insurance (MediGap) policy, I request that payment of authorized MediGap benefits be made to Z-Roc Dermatology directly on my behalf by my MediGap insurer.

c. Payment of Medicare Benefits to Z-Roc Dermatology. I request payment of authorized Medicare benefits to be made either to me or on my behalf to Z-Roc Dermatology for services furnished to me by Z-Roc Dermatology. I authorize any holder of medical information about me to release to the Centers for Medicare and Medicaid Services and its agents any information needed to determine these benefits or the benefits payable for related services.

d. Referrals and Prior Authorizations. I understand and agree that it is my responsibility to know and abide by the terms of my Third-Party Payor coverage, including referral or authorization requirements and other types of benefit limitation. I understand that I am responsible for obtaining any required referrals for specialized care before making appointments. I agree to obtain a required authorization for services or to provide all information needed by Z-Roc Dermatology to obtain a required authorization in advance of my visit. If my Third-Party Payor refuses to cover the services I receive, based on the lack of a required referral or authorization or otherwise, I understand I am financially responsible and agree that I will pay for the services provided by Z-Roc Dermatology, except to the extent such obligation is limited by applicable law or contractual obligations of Z-Roc Dermatology applicable to payment for those services.

e. Full Body Skin Cancer Screenings. I understand and agree that routine full body skin cancer screenings are not covered in full as a preventative service under most health plans, including Medicare. If my Third-Party Payor requires the payment of a copay for these screenings (e.g., as a specialist visit), I agree to pay this copay at the time of service. I further understand that Z-Roc Dermatology will send me an invoice for any coinsurance or deductible balances due, and I agree to timely pay the amount specified on this invoice.

III. NOTICE OF PRIVACY PRACTICES.

a. Confidentiality. It is the policy of Z-Roc Dermatology to protect the privacy and confidentiality of my health information in compliance with applicable law.

b. Notice of Privacy Practices. Z-Roc Dermatology’s Notice of Privacy Practices explains how Z-Roc Dermatology may use and disclose my health information. It also explains my rights regarding this kind of information. Z-Roc Dermatology may revise its Notice of Privacy Practices at any time and will provide me with a copy of the revised Notice of Privacy Practices at my request. Z-Roc Dermatology’s Notice of Privacy Practices is available at each of its clinics and on its website (www.zrocdem.com).

c. Acknowledgment of Receipt. I acknowledge that I have received Z-Roc Dermatology’s Notice of Privacy Practices.

IV. CONSENT FOR TREATMENT.

V. PUBLIC COMMENTS.

I have fully read, understand, and agree to the information contained in this Consent and Authorization Form (“Form”). I have had the chance to ask questions about the information contained in this Form, and all my questions have been answered to my satisfaction. This Form will remain in effect until I revoke it by sending a written request to Z-Roc Dermatology’s Privacy Officer, which I may do at any time. I understand that any such revocation shall not have effect on any actions taken in reliance on this Form before my revocation.

Patient’s Name (please print):*

Patient’s Date of Birth:*

Patient’s Signature (or Patient Representative’s Signature):

Initial Here:*

If you are unable to sign using the patient signature, use this field to enter your initials.

If patient is under the age 18 or unable to provide informed consent:

Representative’s Name (please print):*

Relationship to patient*

LATE ARRIVAL, CANCELLATION AND RETURN POLICY

Late Arrivals

If you are more than 15 minutes late for your appointment, we may reschedule your appointment. We understand that patients sometimes experience unavoidable delays and will do our best to accommodate patients that arrive more than 15 minutes after their scheduled appointment. However, if we are unable to make this accommodation without negatively impacting other patients (e.g., by increasing their wait time), we will work with you to find a new day and time that works well for your schedule. We may decide to terminate our professional relationship with you if you have three or more late arrivals.

“No Show” Appointments

If you do not attend your scheduled appointment without giving us any prior notice, you may be charged a “no show” fee in the amount of $100.00 for cosmetic/surgical. We may decide to terminate our professional relationship with you if you have two or more “no show” appointments.

Late Cancellations

If you cancel an appointment less than 24 hours before the appointment, you may be charged a “no show” fee in the amount of $50.00. We may decide to terminate our professional relationship with you if you cancel two or more appointments with less than 24 hours’ notice.

Surgical Appointment Cancellations

Cancellation of a surgical appointment must be made at least 2–3 days in advance. This allows us ample time to offer the appointment slot to another patient in need. Failure to provide a minimum of 2–3 days’ notice for a cancellation of a surgical appointment may result in a “no show” fee in the amount of $100.00. This fee will be discussed with you at the time of cancellation and will depend on the specific circumstances.

By signing below, I signify that I have read, understand, and agree to this Late Arrival, Cancellation and Return Policy.

Z-Roc Dermatology, LLC (“Z-Roc Dermatology”) healthcare professionals and staff strive to provide timely, convenient, and professional services to our patients. To help achieve this goal, Z-Roc Dermatology has implemented this Late Arrival, Cancellation and Return Policy.

Late Arrivals: If you are more than 15 minutes late for your appointment, we may reschedule your appointment. We understand that patients sometime experience unavoidable delays and will do our best to accommodate patients that arrive more than 15 minutes after their scheduled appointment. However, if we are unable to make this accommodation without negatively impacting other patients (e.g., by increasing their wait time), we will work with you to find a new day and time that works well for your schedule. We may decide to terminate our professional relationship with you if you have three or more late arrivals.
“No Show” Appointments: If you do not attend your scheduled appointment without giving us any prior notice, you may be charged a “no show” fee in the amount of $100.00 for cosmetic/surgical. We may decide to terminate our professional relationship with you if you have two or more “no show” appointments.
Late Cancellations: If you cancel an appointment less than 24 hours before the appointment, you may be charged a “no show” fee in the amount of $50.00. We may decide to terminate our professional relationship with you if you cancel two or more appointments with less than 24 hours’ notice.
Surgical Appointment Cancellations: Cancellation of a surgical appointment must be made at least 2-3 days in advance. This allows us ample time to offer the appointment slot to another patient in need. Failure to provide a minimum of 2-3 days’ notice for a cancellation of a surgical appointment, you may be charged a “no show” fee in the amount of $100.00. This fee will be discussed with you at the time of cancellation and will depend on the specific circumstances.

By signing below, I signify that I have read, understand, and agree to this Late Arrival, Cancellation and Return Policy.

Patient’s Name (please print):*

Patient’s Date of Birth:*

Patient’s Signature (or Patient Representative’s Signature):

Initial Here:*

If you are unable to sign using the patient signature, use this field to enter your initials.

Today’s Date:*

If patient is under the age 18 or unable to provide informed consent:

Representative’s Name (please print):*

Relationship to patient*

*** Please talk with Z-Roc Dermatology’s business office about no-shows and late cancellations caused by an emergency. ***

INFORMED CONSENT FOR TREATMENT AND
THE PERFORMANCE OF MINOR SURGERIES AND/OR PROCEDURES

Please read and be certain that you understand the information contained in this form. This form is a consent for the treatment described below, and contains a summary of the risks and benefits associated with the treatment. Before you receive the treatment, your provider will provide you with additional information about these risks and benefits and answer any questions that you may have about the treatment or related matters. If you have any questions or concerns at any time, please contact your provider.

General Consent to Treatment

My provider and I have discussed the treatment(s) and/or procedure(s) that have been deemed advisable, desirable, or necessary for diagnostic, therapeutic or investigational purposes for me or my minor child (collectively, “Treatment”), and I understand that such Treatment may involve the administration of drugs and anesthetics, the performance of a skin biopsy, the use of cryosurgery with liquid nitrogen and/or the injection of triamcinolone (cortisone). During these discussions, my provider told me about the Treatment’s intended purpose, risks and potential side effects, benefits, alternatives, and related information, and I had the opportunity to ask any questions that I may have had, all of which have been answered to my satisfaction. Based on this discussion and any related written materials that have been provided to me, I hereby consent to Z-Roc Dermatology, LLC (“Z-Roc Dermatology”) administration of the Treatment to me or to my minor child.

Consent to Skin Biopsy, Testing and Disposal

Biopsy

I understand that skin biopsies involve the removal of a piece of skin and may result in a permanent mark, scar or skin discoloration at the site of the biopsy, and that more than one biopsy may occur during a single visit. I consent to the performance of a skin biopsy(ies) when deemed necessary by my provider for the purposes of diagnosis or treatment. I understand that based on the results of the pathology, I may need to have additional tissue removed at a future office visit and that this will result in an additional charge.

Testing

I understand and agree that (1) any tissue sample obtained during the Treatment will undergo a dermatopathological analysis, which is conducted by specially trained providers in a laboratory setting, the results of which will assist in the development of a diagnosis and treatment plan; (2) such analysis may be conducted by a third party (i.e., an entity other than Z-Roc Dermatology); and (3) additional testing and/or a second opinion may be needed to obtain a definitive diagnosis and develop the most appropriate treatment plan. I further understand and agree that any such analysis will be billed to my insurance, and that I am personally responsible for paying any charges relating to such analysis that are not paid for by my insurance.

Disposal

I consent to the disposal of any tissue sample obtained by or on behalf of Z-Roc Dermatology when such samples are no longer needed or viable for testing.

Consent to Use of Liquid Nitrogen

Precancerous Lesions

I understand and consent to the destruction with liquid nitrogen of precancerous lesions, which are also known as actinic keratoses or solar keratoses, when deemed necessary or advisable by my provider to prevent the risk that these lesions will evolve into squamous cell carcinomas (a form of skin cancer). I understand that these lesions may require more than a single treatment.

Warts or Mollusca

I understand and consent to the destruction with liquid nitrogen of potentially contagious warts or mollusca, which are not cancerous and do not absolutely require treatment, when deemed necessary or advisable by my provider to prevent their spread. I further understand and agree that the destruction of a wart or mollusca may require multiple treatments.

Consent to Injection of Triamcinolone (Cortisone)

I understand and consent to the injection of triamcinolone (cortisone) when deemed necessary or advisable by my provider for the treatment of scars, cysts, acne and/or inflammatory conditions like psoriasis, atopic dermatitis and alopecia areata.

Risks and Possible Side Effects

The risks and possible side effects of the Treatment include, but are not limited to, the following:

Permanent scarring
Permanent discoloration of the skin at the site of treatment
Atrophy (thinning or depression of the skin)
Infection
Bleeding
Nerve damage resulting in temporary or permanent numbness or temporary or permanent loss of function of certain muscles (paralysis)
Surgical site re-opening—including, but not limited to, movement, weight bearing, personal medical history, and wound location

The above list is not meant to be inclusive of all possible risks associated with the Treatment, as there are both known and unknown side effects and complications associated with any treatment or procedure.

ACKNOWLEDGEMENTS. By signing below, I acknowledge and agree to the statements listed above and the following:

The nature and purpose of the Treatment has been explained to me, and I understand the information contained on this form in its entirety.
I understand the risks associated with the Treatment and the alternative treatment methods have been explained to me. I know that I have the right to refuse the Treatment and, by signing below, I am consenting to the Treatment and accepting the associated risks and possible complications.
I understand that medical attention may be required to address complications associated with the Treatment.
I understand that the results of the Treatment are not guaranteed.
I understand that any rescheduling of an appointment must be done at least 24 hours before the appointment and that, if I fail to timely cancel or reschedule an appointment, I may be billed for my missed appointment consistent with Z-Roc Dermatology’s Late Arrival, Cancellation and Return Policy.
I understand and agree that all services rendered to me may be charged to me directly and that I am personally responsible for payment for the full cost of the Treatment.
I certify that I am a competent adult of at least 18 years of age and that this consent form is signed freely and voluntarily. I hereby release any right to claim that the performance of any operation or procedure provided to me was not properly authorized.

Please read and be certain that you understand the information contained in this form. This form is a consent for the treatment described below, and contains a summary of the risks and benefits associated with the treatment. Before you receive the treatment, your provider will provide you with additional information about these risks and benefits and answer any questions that you may have about the treatment or related matters. If you have any questions or concerns at any time, please contact your provider.

1. General Consent to Treatment.

My provider and I have discussed the treatment(s) and/or procedure(s) that have been deemed advisable, desirable, or necessary for diagnostic, therapeutic or investigational purposes for me or my minor child (collectively, “Treatment”), and I understand that such Treatment may include the administration of drugs and anesthetics; the performance of a skin biopsy; the destruction of a wart with liquid nitrogen and/or the injection of triamcinolone (cortisone). During these discussions, my provider has told me about the Treatment’s intended purpose, risks and potential side effects, benefits, alternatives, and related information. I understand the Treatment to my and/or my minor child. I have had, or will have the opportunity to ask questions related to the above areas of discussion and any related written materials that have been provided to me. I hereby consent to Z-Roc Dermatology LLC (“Z-Roc Dermatology”) administration of the Treatment to me or my minor child.

2. Consent to Skin Biopsy, Testing and Disposal.

a. Biopsy. I understand that skin biopsies involve the removal of a piece of skin and may result in a permanent mark, scar or skin discoloration at the site of the biopsy, and that more than one biopsy site may be necessary. I also understand that the site of biopsy, and that more than one biopsy site may be deemed necessary by the provider for the purposes of diagnosis or treatment. I understand that based on the results of the pathological examination of the tissue removed a further office visit will though that this will result in an additional charge.

b. Testing. I understand and agree that (1) any tissue sample obtained during the Treatment will undergo a dermatopathological analysis, which is conducted by specially trained individuals trained in the field of dermatopathology; (2) this analysis typically performed at an offsite pathology and treatment plan; (3) such analysis may be conducted by another party (i.e. an independent laboratory not affiliated with Z-Roc Dermatology); and (4) I agree to accept the risks associated with the performance of a biopsy diagnosis and review the bill for my insurance provider. I am personally responsible for paying any charges such analysis will be subject to any applicable remaining balance after insurance.

c. Disposal. I consent to the disposal of any tissue sample obtained by me, or on behalf of Z-Roc Dermatology in a manner required by law or deemed more suitable for viably for testing.

3. Consent to Use of Liquid Nitrogen to Treat Precancerous Lesions, Warts and Molluscum.

a. Precancerous Lesions. I understand and consent to destruction of skin tissue with liquid nitrogen or cryotherapy. I understand that cryotherapy is used to treat lesions on the skin that are thought to be actinic keratoses (also known as “pre-cancers), which are areas of the skin that show early abnormal skin changes (a form of skin cancer). I understand that these lesions may require more than a single treatment.

b. Warts or Molluscum. I understand and consent to the destruction with liquid nitrogen of potentially contagious warts or mollusc, which are not cancerous and do not absolutely require treatment, when deemed necessary or advisable by my provider to prevent their spread. I further understand and agree that the destruction of a wart or mollusc may require multiple treatments.

4. Consent to Injection of Triamcinolone (Cortisone).

5. Risks and Possible Side Effects.

The risks and possible side effects of the Treatment include, but are not limited to, the following:

Permanent scarring
Permanent discoloration of the skin at the site of treatment
Atrophy (thinning or depression of the skin)
Infection
Bleeding
Nerve damage resulting in temporary or permanent numbness or temporary or permanent loss of function of certain muscles (paralysis)
Surgical site re-opening including but not limited to the following factors; movement, weight bearing, personal medical history and wound location.

The above list is not to be inclusive of all possible risks associated with the Treatment as there are both known and unknown side effects and complications associated with any treatment or procedure.

ACKNOWLEDGEMENTS.

By signing below, I acknowledge and agree to the statements listed above and the following:

The nature and purpose of the Treatment has been explained to me, and I understand the information contained on this form in its entirety.
I understand the risks associated with the Treatment and the alternative treatment methods have been explained to me. I know that I have the right to refuse the Treatment, and by signing below, I am consenting to the Treatment and accepting the associated risks and possible side effects.
I understand that medical attention may be required to address complications associated with treatment.
I understand that any rescheduling of an appointment must be done at least 24 hours before the appointment and that, if I fail to timely cancel or reschedule an appointment, I may be held for my missed appointment consistent with Z-Roc Dermatology’s Late Arrival, Cancellation and Return Policy.
I understand and agree that all services rendered to me may be charged to my direction and that I am personally responsible for payment of the full cost of the Treatment.
I certify that I am a competent adult of at least 18 years of age and that this consent form is signed freely and voluntarily. I hereby release the right to claim that the performance of any operation or procedure provided to me was not properly authorized.

Patient’s Name (please print):*

Patient’s Date of Birth:*

Patient’s Signature (or Patient Representative’s Signature):

Initial Here:*

If you are unable to sign using the patient signature, use this field to enter your initials.

Today’s Date:*

If patient is under the age 18 or unable to provide informed consent:

Representative’s Name (please print):*

Relationship to patient*

Patient’s Name (please print):*

Patient’s Date of Birth:*

Please answer the following questions to the best of your ability.
Please note that the United States Federal Government REQUIRES us to ask these questions.

1. Do you currently smoke cigarettes or use smokeless tobacco?*

Yes

I AM A FORMER SMOKER

2. If you answered YES to Question #1, are you aware of resources available to help you quit smoking?*

Yes

3. Patients 65 years of age and older: Do you have a health care proxy in the event you are unable to make your own medical decisions?*

Yes

I AM A FORMER SMOKER

4. If you answered YES to Question #3, please list your designee’s name and phone number below:*

5. Patients 65 years of age and older: Do you have a living will?*

Yes

6. Patients 13-18 years of age: Did you receive one dose of meningococcal (meningitis) vaccine on or between your 11th and 13th birthdays?*

Yes

7. Patients 13-18 years of age: Did you receive one tetanus, diphtheria, and pertussis (Tdap) vaccine on or between your 10th and 13th birthdays?*

Yes

8. Patients age 13-18 years of age: Have you had at least three HPV vaccines on or between your 9th and 13th birthdays?*

Yes

PATIENT INTAKE FORM

PATIENT INTAKE FORM

Responsible Party (if different from patient)

Pharmacy Information (What is your primary choice)

Are you currently:

CONSENT TO COMMUNICATIONS

Please check all that apply:

CONSENT AND AUTHORIZATION FORM

Consent and Authorization for the Release of Information

Release of Information

Payment Responsibility and Authorization

Payment Responsibility

Payment Authorization

Payment of Medicare Benefits to Z-Roc Dermatology

Referrals and Prior Authorizations

Full Body Skin Cancer Screenings

Notice of Privacy Practices

Confidentiality

Notice of Privacy Practices

Consent for Treatment

Public Comments

I. CONSENT AND AUTHORIZATION FOR THE RELEASE OF INFORMATION.

II. PAYMENT RESPONSIBILITY AND AUTHORIZATION.

III. NOTICE OF PRIVACY PRACTICES.

IV. CONSENT FOR TREATMENT.

V. PUBLIC COMMENTS.

LATE ARRIVAL, CANCELLATION AND RETURN POLICY

Late Arrivals

“No Show” Appointments

Late Cancellations

Surgical Appointment Cancellations

INFORMED CONSENT FOR TREATMENT AND THE PERFORMANCE OF MINOR SURGERIES AND/OR PROCEDURES

General Consent to Treatment

Consent to Skin Biopsy, Testing and Disposal

Biopsy

Testing

Disposal

Consent to Use of Liquid Nitrogen

Precancerous Lesions

Warts or Mollusca

Consent to Injection of Triamcinolone (Cortisone)

Risks and Possible Side Effects

1. General Consent to Treatment.

2. Consent to Skin Biopsy, Testing and Disposal.

3. Consent to Use of Liquid Nitrogen to Treat Precancerous Lesions, Warts and Molluscum.

4. Consent to Injection of Triamcinolone (Cortisone).

5. Risks and Possible Side Effects.

ACKNOWLEDGEMENTS.

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INFORMED CONSENT FOR TREATMENT AND
THE PERFORMANCE OF MINOR SURGERIES AND/OR PROCEDURES