First Capitol Surgical Dermatology

Registration Form

Do you have an Advance Care Plan?  
Insurance Information
Do you have Healthcare Insurance?   
Medical History
Check any of the following medical conditions that pertain to you, past or present:

Skin Cancer History  
Artificial Joint?  
Family history of skin cancer  
Social History
Marital Status  
Do you smoke or use tobacco products?  
Do you drink alcohol?  
Current Medications

Did you enter ALL of your medications above?  
Do you take blood thinners (including aspirin, fish oil)?  
Do you take antibiotics prior to procedures?  
Medication Allergies

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