Home » General Appointment » Patient Registration Form Patient Information First Name * Middle Initial Last Name * Date of Birth * [mmddyyyy] Address * City * State * Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code * Cell Number* (with area code) Work Phone * (with area code) Home Phone * (with area code) Email Address * Gender * Select your gender Male Female Marital Status * Select One Married Single Divorced Widowed Spouse's Name In an EMERGENCY, who should be notified? 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 select all those that apply Yes No Do you smoke? * Yes No Do you vape? * Yes No Do you go to a tanning salon? * Yes No Are you allergic to dental anesthesia? (Novocain, Lidocaine, Xylocaine ) * 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? * Please select all those that apply 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 or Defibrillator * 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: Please select all those that apply Check all that apply UVB Light Therapy PUVA Light Therapy Systemic PUVA Light Therapy Topical Cyclosporine by mouth Methotrexate by mouth or injection Retinoids by mouth (Tegison, Soriatane, acitretin) Imuran (Azathioprine) Remicade (Infliximab) Humira (Adalimumab) Simponi (Golimumab) Stelara (Ustikinumab) Taltz (Ixekizumab) Otezla (Apremilast) Cortisone (steroids) by mouth Cortisone (steroids) injected into arm or buttock Cortisone (steroids) injected into psoriasis plaques Cortisone (steroids) rubbed into skin Retinoids (Differin, Tazorac, Retin-A) rubbed into skin Calcipotriene (Dovonex, Taclonex, Vectical) rubbed into skin Pulse Dye Laser XTRAC Laser Please continue to the next step, you can come back to this page if needed. Hidradenitis Suppurativa Prior Therapy History Name: DOB: Please select all those that apply Check all that apply Loose cotton clothing Domeboro (aluminum acetate), Burows solution Clinical strength anti-perspirants Zinc gluconate tablets by mouth Clindamycin solution rubbed on skin Dapsone cream rubbed on skin Steroids by mouth Cortisone injected into muscle Cortisone injected into affected skin Methotrexate by mouth or injection Accutane (isotretinoin) by mouth Soriatane (acitretin) by mouth Spironolactone by mouth Finasteride by mouth Dutasteride by mouth Robinul (glycopyrrolate) by mouth Cyclosporine by mouth Azathioprine (Imuran) by mouth Infliximab (Remicade) by intravenous Adalimumab (Humira) by injection Golimumab (Simponi) by injection Ustekinumab (Stelara) by injection Anakinra (Kineret) by injection Hair removal laser Lancing of boils (incision and drainage) Wide surgical excision HS unroofing HS CO2 laser surgery Please continue to the next step, you can come back to this page if needed. Vitiligo Prior Therapy History Name: DOB: Please select all those that apply Check all that apply Cortisone (steroids) rubbed on skin Protopic rubbed on skin Elidel rubbed on skin Pseudocatalase cream Cortisone (steroids) by mouth Cortisone (steroids) injected into Vitiligo patches Vitamin therapy Aspirin Therapy Narrowband UV light in stand-up box Narrowband UV light with handheld wand PUVA (UVA light with Psoralen by mouth) UV laser Vitiligo Minigraft surgery 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 * 01-25-2020 If you are consulting Dr Resnik for Psoriasis, Please Click here If you are consulting Dr Resnik for Hidradenitis Suppurativa, Please Click here If you are consulting Dr Resnik for Vitiligo, Please Click here If not, Please Click here 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.
