Registration Form

Patient First Name

Last Name

DOB

Address

City

State

Zip

Phone

Email

Primary Care Physician

Pharmacy

Do you have an Advance Care Plan?
Yes No

Height

Weight
lbs.

Insurance Information

Do you have Healthcare Insurance?
Yes No

Medical History

Check any of the following medical conditions that pertain to you, past or present:

Other medical conditions not listed

Skin Cancer History
Melanoma Basal Cell Squamous Cell None

Artificial Joint?
Yes No

Past Surgeries

Family history of skin cancer
Melanoma Basal Cell Squamous Cell Unknown

Relationship to patient

Social History

Marital Status
Single Married Divorced Widowed

Do you smoke or use tobacco products?
Yes No

Do you drink alcohol?
Yes No

Current Medications

Name

Dosage

Frequency

Route

Add another?

Did you enter ALL of your medications above?
Yes No

Do you take blood thinners (including aspirin, fish oil)?
Yes No

Do you take antibiotics prior to procedures?
Yes No

Medication Allergies

Allergen

Reaction

Add another?

Other: (ex: latex, contrast dye)

Signature of Patient or Legal Guardian – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.

Date