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

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 * 09-19-2019
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.