PATIENT INFORMATION Appointment Date: _____________________ Time: _____________ with Dr.

________________

Last Name______________________________________________First Name____________________________________ M.I.___________

Mailing Address _____________________________________________________________________________________________________

Street Address________________________________________________________________________________________________________

City____________________________________________________________________State__________________Zip___________________

Sex: M / F Marital Status: (circle one) M S W D Spouse’s Name___________________________________________________

Social Sec. #_______________________________________________ Date Of Birth________________________________Age___________

Home Phone#_______________________________Work Phone #____________________________ Cell _____________________________

Referred By: (Please Circle One) Family member Doctor Friend Yellow pages Newspaper Ad

Referring Doctor:________________________________________________ Phone # _____________________________________________

PCP (Primary Care Physician): ____________________________________ Phone # _____________________________________________

Your Employer__________________________________________________ Phone # _____________________________________________

Pharmacy: ______________________________________________ Pharmacy Telephone Number: ________________________________

Emergency Contact : ________________________________________________________ Phone Number: ___________________________

Name Relationship
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PRIMARY INSURANCE: (patients without current insurance card at time of service will be considered self-pay unless cards received within 30 days)

Insurance Company: __________________________________________________________________________________________________

Ins. ID/ Member #: _________________________________________ Group #/ Name: ___________________________________________

Subscriber Name: __________________________________________ Subscriber’s Date of Birth: __________________________________

Subscriber’s Relationship to Patient: ____________________________________________________________________________________

Subscriber’s Address:_________________________________________________________________________________________________

City________________________________________________________________State_____________________Zip____________________

Home Phone: _______________________________ Work Phone: ________________________________ SS# ________________________

Employer: __________________________________________________________________________________________________________
*******************************************************************************************************************************************************************************

SECONDARY INSURANCE:

Insurance Company: __________________________________________________________________________________________________

Ins. ID/ Member #: _________________________________________ Group #/ Name: ___________________________________________

Subscriber Name: __________________________________________ Subscriber’s Date of Birth: __________________________________

Address: ______________________________________________________ City/ST _____________________________________________

Home Phone: _______________________________ Work Phone: ________________________________ SS# ________________________

Employer: __________________________________________________________________________________________________________
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HIPAA INFORMATION: A copy of our privacy policy will be provided to you at your appointment.

I have been notified of the Skin Cancer and Dermatology Center of Colorado Springs, P.C. privacy policy.

___________________________________________________ ____________________________________________
Patient Signature Date
 PATIENT HISTORY

NAME: APPT. DATE:

Where is your problem?
When did you first get the skin problem?
Where did it first start?
Has it been there all the time since then? NO YES
Have you ever had the same skin problem before? NO YES
Have you ever had a different skin problem in the past? NO YES

PLEASE DRAW ON THIS CHART WHERE YOUR PRESENT SKIN PROBLEM OR RASH IS BY SHADING IN.

NOTES

MEDICINES:
MEDS:
Has your doctor given you anything for the skin?………….….. NO YES Please give names of all substances
used.

Have you put anything else on the skin yourself?…….….…… NO YES Please give names of all substances
used.

Are you taking any pills, medicines, tablets or drugs regularly? NO YES What? Please give exact names.

Do you take any of the following tablets or medicines?

Cortisone drugs…………...……………………………..………….. NO YES

Aspirin or pain killers……………………….……………………….. NO YES

"Nerve Pills" sedatives or tranquilizers……………..…………….. NO YES
Laxatives (for constipation)………………………………………. NO YES
Contraceptive pills…………………………………………………. NO YES
Blood Thinners…………………………………………………… NO YES
Have you had any bad reactions to any drugs?……………… NO YES
Which ones?

(OVER)
GENERAL (SOCIAL HISTORY)
What is your present work or occupation?
What types of work have you done in the past?
Do you have any special hobbies? NO YES
Do you take part in any sports? (e.g. swimming) NO YES
Do you smoke tobacco? NO YES
Do you drink alcohol? NO YES
Do you have any pets? NO YES
Have you traveled abroad over the last two years? NO YES
Have you ever traveled or lived outside the USA? NO YES

RELATIVES AND FAMILY

Do any of your relatives or family have the following illnesses? Which relatives? Please write the disease.

Hay fever, eczema or asthma (wheezy chest) NO YES

Psoriasis NO YES
Any other skin problems NO YES
Diabetes or T.B. NO YES
Does any member of the family or friend have the same skin
problem as yours? NO YES

PAST HISTORY
Are you under MEDICAL treatment now? NO YES
If so, for what?

Have you ever had any SURGERY? NO YES

If so, what?
When?

DO YOU OR HAVE YOU EVER HAD:

Heart Trouble/Rheumatic Fever NO YES Fever Blisters/Cold Sores NO YES

High Blood Pressure NO YES Tuberculosis NO YES
Pacemaker NO YES Bad Teeth NO YES
Frequent or Severe headache NO YES Cough NO YES
Epilepsy/Stroke NO YES Recent Nausea or Vomiting NO YES
Bleeding Problems NO YES Recent Diarrhea NO YES
Fingers turn colors when cold NO YES Recent Indigestion NO YES
Arthritis NO YES Loss of Appetite NO YES
Difficulty Swallowing NO YES Swollen Glands NO YES
Shortness of Breath NO YES Weight Loss NO YES
Chest Pain NO YES Diabetes NO YES
Keloids or Abnormal Scars NO YES Thyroid Condition NO YES
Eczema NO YES Hepatitis/Liver Disease NO YES
Hay Fever/Sinus NO YES Stomach Ulcers NO YES
Asthma NO YES Cancer NO YES
Sinus Infection NO YES Are you Pregnant? NO YES
Ear Infection NO YES
Kidney or Bladder Trouble NO YES
Brett K. Matheson, M.D.
Christopher R. Sartori, M.D.
595 Chapel Hills Drive, Suite 303
Colorado Springs, CO 80920
History Reviewed By Date Phone (719) 574-0310
 SKIN CANCER & DERMATOLOGY CENTER OF COLORADO SPRINGS, P.C.
595 Chapel Hills Drive, Suite 303, Colorado Springs, CO 80920
FINANCIAL POLICY AND PATIENT AGREEMENT

The following is the financial policy of the Practice, which we require that you read, and sign prior to treatment:

In order to establish optimal relations with our patients and avoid misunderstanding regarding our payment policies,
our staff is trained to inform you of the financial policies of this office. PAYMENT IS EXPECTED FROM YOU, AT
THE TIME OF SERVICE, FOR “YOUR PART” OF THE CHARGES. WE ACCEPT CASH, CHECK, VISA, AND
MASTERCARD, DISCOVER, AND AMERICAN EXPRESS FOR YOUR CONVENIENCE.

Insurance:

The patient must recognize that he/she is responsible to pay the full amount for all services unless the Practice has
an agreement with the patients’ insurance carrier for alternative payments. As a courtesy to patients, the Practice
will file insurance claims with all standard insurance carriers. The patient is responsible to make available to the
Practice complete insurance information, for accurate filing of claims. Insurance information includes
referrals from other providers for primary and secondary insurance coverage, all identification and benefits
cards/documents. The patient agrees that if the insurance company denies benefits for any reason, that the
patient is responsible for the full amount of the bill immediately.

The practice’s policy on accepting insurance payments varies based on the type of insurance as follows:

INDEMNITY-TYPE INSURANCE – insurance payments received by the Practice will be applied to the patient’s
account and the patient agrees to pay the balance. Co-Payments are due at the time of service and are collected
before service is provided.

HMO’s and PPO’s – If the Practice has an agreement with the patient’s insurance carrier, we will accept payment
from the carrier for services covered by the patient’s benefit plan. Co-Payments are due at the time of service and
are collected before service is provided. For services not covered by the patient’s benefit plan, payment is due at
the time of service.

MEDICARE—The practice accepts assignment from Medicare. Therefore, the patient agrees to pay the Practice
the Medicare coinsurance PLUS any amount of the patient’s deductible that is not yet paid and any service not
covered by Medicare. Regulations pertaining to Medicare assignment of benefits apply.

By this agreement, the patient also authorizes the exchange of information relating to care and claims with the
patient’s insurance company(s), its intermediaries, carriers, and referring physician and authorizes insurance
payments to be made directly to the Physician for services provided under the patient’s insurance agreement and
otherwise payable to the patient.

The patient understands that delinquent accounts are subject to finance charges and collection fees, and that
special financial arrangements can only be made with an addendum to this document.

PATIENT AGREEMENT: I have read and understand the financial policy above and agree to the terms
stated.

_____________________________________ ______________________________________
Patient’s Signature/Guardian Date

MEDIGAP: If you have a supplemental policy and it is a MEDIGAP policy to which your Medicare Carrier
automatically “crosses over”, we are required to keep a separate signature on file:

I request authorized MEDIGAP benefits be made on my behalf for any services furnished to me. I authorize the
Practice to release to my MEDIGAP carrier any information needed to determine benefits or the benefits payable
for related services.

_____________________________________ ______________________________________
Signature as it appears on Medigap Card Date