Patient Information
First Name *
Middle Initial
Last Name *
Date of Birth *
[mmddyyyy]
Address *
City *
State *
Zip Code *
Cell Number*
(with area code)
  
Work Phone *
(with area code)
  
Home Phone *
(with area code)
  
Email Address *
Gender *
Marital Status *
Spouse's Name
In an EMERGENCY, who should be notified?
Name Relationship Phone
Name Relationship Phone

Insurance Information
If you have insurance, Please call the office to verify your coverage.

Please continue to the next step, you can come back to this page if needed.
Dermatology Medical History Name: 
DOB: 
Please answer the following
Yes No Do you smoke? *
Yes No Do you go to a tanning salon? *
Yes No Are you allergic to dental anesthesia? (Novocain) *
Yes No Have you ever had skin cancer? *
Yes No Has anyone in your family had skin cancer? *
Yes No Do you have problems with healing? *
Yes No Do you develop keloids (scars) after surgery? *
Yes No Do you take blood Thinners or aspirin? *
Do you have?
Yes No Skin rashes to medications *
Yes No Skin rashes to foods *
Yes No Skin rashes to environment *
Yes No Diabetes *
Yes No Thyroid problems *
Yes No Pacemaker *
Yes No Kidney problems *
Yes No Artificial joint *
Yes No Stomach problems *
Yes No High Blood Pressure *
Yes No Epilepsy *
Yes No History of Internal Cancer *
Yes No Migraines *
Yes No Asthma *
Yes No Leg vein inflammation *
Any surgical procedures in the last 6 months? * Yes No
Do you have allergies to any medicines? * Yes No
Medicines, prescribed or over-the-counter
 
Psoriasis Prior Therapy History Name: 
DOB: 
What treatments have you tried? Check all that apply
UVB Light Therapy Yes No
PUVA Light Therapy Systemic Yes No
PUVA Light Therapy Topical Yes No
Cyclosporine by mouth Yes No
Methotrexate by mouth or injection Yes No
Retinoids by mouth (Tegison, Soriatane, acitretin) Yes No
Imuran (Azathioprine) Yes No
Enbrel (Etanercept) Yes No
Remicade (Infliximab) Yes No
Humira (Adalimumab) Yes No
Simponi (Golimumab) Yes No
Stelara (Ustikinumab) Yes No
Taltz (Ixekizumab) Yes No
Otezla (Apremilast) Yes No
Cortisone (steroids) by mouth Yes No
Cortisone (steroids) injected into arm or buttock Yes No
Cortisone (steroids) injected into psoriasis plaques Yes No
Cortisone (steroids) rubbed into skin Yes No
Retinoids (Differin, Tazorac, Retin-A) rubbed into skin Yes No
Calcipotriene (Dovonex, Taclonex, Vectical) rubbed into skin Yes No
Pulse Dye Laser Yes No
XTRAC Laser Yes No
Please continue to the next step, you can come back to this page if needed.
 
Hidradenitis Suppurativa Prior Therapy History Name: 
DOB: 
What treatments have you tried? Check all that apply
Loose cotton clothing Yes No
Domeboro (aluminum acetate), Burows solution Yes No
Clinical strength anti-perspirants Yes No
Zinc gluconate tablets by mouth Yes No
Clindamycin solution rubbed on skin Yes No
Dapsone cream rubbed on skin Yes No
Cortisone cream rubbed on skin Yes No
Prednisone or Medrol Pak by mouth Yes No
Cortisone injected into muscle Yes No
Cortisone injected into affected skin Yes No
Methotrexate by mouth or injection Yes No
Accutane (isotretinoin) by mouth Yes No
Soriatane (acitretin) by mouth Yes No
Spironolactone by mouth Yes No
Finasteride by mouth Yes No
Dutasteride by mouth Yes No
Robinul (glycopyrrolate) by mouth Yes No
Cyclosporine by mouth Yes No
Azathioprine (Imuran) by mouth Yes No
Etanercept (Enbrel) by injection Yes No
Infliximab (Remicade) by intravenous Yes No
Adalimumab (Humira) by injection Yes No
Golimumab (Simponi) by injection Yes No
Ustekinumab (Stelara) by injection Yes No
Anakinra (Kineret) by injection Yes No
Hair removal laser Yes No
Lancing of boils (incision and drainage) Yes No
Wide surgical excision Yes No
HS unroofing Yes No
HS CO2 laser surgery Yes No
Please continue to the next step, you can come back to this page if needed.
 
Vitiligo Prior Therapy History Name: 
DOB: 
Treatment Check all that apply
Cortisone (steroids) rubbed on skin Yes No
Protopic rubbed on skin Yes No
Elidel rubbed on skin Yes No
Pseudocatalase cream Yes No
Cortisone (steroids) by mouth Yes No
Cortisone (steroids) injected into Vitiligo patches Yes No
Vitamin therapy Yes No
Aspirin Therapy Yes No
Narrowband UV light in stand-up box Yes No
Narrowband UV light with handheld wand Yes No
PUVA (UVA light with Psoralen by mouth) Yes No
UV laser Yes No
Vitiligo Minigraft surgery Yes No
Please continue to the next step, you can come back to this page if needed.
 
Get the Latest Information Name: 
DOB: 
We periodically send e-mail or text messages with the latest information from Resnik Skin Institute, from new product information and product promotions to the latest in cutting edge skin care. We will never give or sell your information to anyone or any business. Completing this form gives us permission to add you to our list. You can “unsubscribe” at any time with a single click on the link at the bottom of every email message we send.
Email *
E-Prescription Service
We are now submitting prescriptions electronically, to make your life easier and to be in compliance with federal mandates. Please give us the name, telephone and zip code of the pharmacy you would like to have as your primary pharmacy.
Pharmacy Name
Telephone
Zipcode

Notice of HIPAA Acceptance Name: 
DOB: 
You acknowledge by your signature below that you have read and agreed to our policy on Access to your Protected Health Information. Simply stated, you must provide us with a signed Records Release before any part of your medical record can be given to anyone. If you wish Dr Resnik to discuss your medical record with anyone, you must either list them here or sign a Release of Information to Third Party. The protection of your medical record is our greatest responsibility.
Name Relationship to Patient
* I certify as my signature the information submitted is accurate.
My mobile phone number is: *
Patient signature Date
Please remember to bring your insurance card and a picture ID

If you have any questions regarding this form or questions, please call (305) 692-8998 and speak with one of our registration specialists.