Ph: (208) 424-9101
Office Hours: Mon-Wed 7:00am - 5:15pm
Thurs       7:30am - 5:00pm
Friday      8:00am - 4:00pm

Patient Registration

As a new patient, it can be time-consuming to fill out all the forms in the office before an appointment. By sending us the information before coming in, we can be better prepared to treat you.


All information is sent and stored using strong encryption methods.
No private health information can be read by third parties.

Feel free to view and print our privacy policy. (opens a new window)
By submitting your information to us, you indicate that you have read our privacy policy.

If you would prefer to fill out the forms on paper, feel free to print them out.

General Information

* Are you a new patient?
 /   / 
May we leave voicemails?
Can we send you text reminders?
May we send you emails?
 
* Is the patient a minor under the age of 18?
Please indicate if parents are:

Person Responsible for Billing

 /   / 

Emergency Contact

Medical Insurance Information

 /   /   /   / 
Hang in there, you're almost halfway done!

Medical History




Pharmacy









Are we allowed to discuss billing and medical record information with anyone besides yourself?



Past Medical History

Have you ever had any type of cancer? :
Anxiety
Arthritis
Asthma
A Fib (irregular heartbeat)
Bone Marrow Transplant
BPH (enlarged prostate)
Breast Cancer
Colon Cancer
COPD
Coronary Artery Disease
Depression
Diabetes
End Stage Renal Disease
Gastric Reflux
Hearing Loss
Do you have or have you been exposed to Hepatitis?
If yes:
Hypertension
HIV/AIDS
High Cholesterol
Hyperthyroidism
Hypothyroidism
Leukemia
Lung Cancer
Lymphoma
Prostate Cancer
Radiation Treatment
Seizures
Stroke

Past Surgical History


Please list all past surgical history. This can include but is not limited to:
Appendix: (Appendectomy)
Bladder: (Cystectomy)
Breast: Breast Biopsy
Breast: Lumpectomy (Left / Right / Both)
Breast: Mastectomy (Left / Right / Both)
Colon: (Colectomy) Colon Cancer Resection
Colon: (Colectomy) Diverticulitis or IBD
Colon: Colostomy
Gallbladder: (Cholecystectomy)
Heart: Biological Valve Replacement
Heart: Coronary Artery Bypass Surgery
Heart: Heart Transplant
Heart: Mechanical Valve Replacement
Heart: PTCA
Joint Replacement: Hip (Left / Right / Both)
Joint Replacement: Knee (Left / Right / Both)
Kidney: Kidney Biopsy
Kidney: Kidney Stone Removal
Kidney: Kidney Transplant
Kidney: Nephrectomy
Liver: Hepatectomy
Liver: Liver Transplant
Liver: Shunt
Ovaries: (Oophorectomy) Endometriosis
Ovaries: (Oophorectomy) Ovarian Cancer
Ovaries: (Oophorectomy) Ovarian Cyst
Ovaries: Tubal Ligation
Pancreas: Pancreatectomy
Prostate: (Prostatectomy) Prostate Biopsy
Prostate: (Prostatectomy) Prostate Cancer
Prostate: (Prostatectomy) TURP
Rectum: APR or low anterior resection
Skin: Basal Cell Carcinoma
Skin: Melanoma
Skin: Skin Biopsy
Skin: Squamous Cell Carcinoma
Spleen: (Splenectomy)
Testicles: (Orchiectomy)
Uterus: (Hysterectomy) Fibroids
Uterus: (Hysterectomy) Uterine Cancer
Uterus: (Hysterectomy) Cervical Cancer

Skin Disease History

Acne
Actinic Keratoses
Basal Cell Skin Cancer
Blistering Sunburns
Cold sores or fever blisters
Dry Skin
Eczema
Flaking or Itchy Scalp
Hay Fever / Allergies
Melanoma
Poison Ivy
Precancerous Moles
Psoriasis
Rash while in the sun
Squamous Cell Skin Cancer
Do you wear sunscreen? :
Do you tan in a tanning salon? :

Family History

* Family history of Melanoma? :
* Skin Cancer (Basal Cell or Squamous Cell)? :
* Psoriasis :
* Eczema :
* Other Skin Diseases in the family? :

Medications: Please list any medications you are currently taking by mouth and those you are applying to your skin. Include birth control pill, over-the-counter medications such as aspirin and vitamins / supplements, and medications that you only take occasionally.

Medication - Dose - Frequency - Start Date
Use a new line for each medication.

Allergies

* Are you allergic to any medications or latex?

Social History

Do you drink alcohol? :
 
Do you use tobacco? :
 
Illicit Drug Use:

Do you use any skin moisturizers or lotions?
:
 
Do you use any anti-aging products?
:
 
 
 
Would you like a cosmetic skin rejuvenation and anti-aging consultation?
 
Would you like to receive periodic cosmetic specials by email?
 
 
Do you already have an appointment scheduled with us?

Patients are responsible for co-pays, deductibles, and/or co-insurance at the time of service.
   *

Alerts

Are you experiencing, or have you experienced any of the following? (check all that apply)
Are you a cosmetic patient (planning to see an esthetician)?

Cosmetic Intake




Have you recently had any of the following:

Waxing / Hair Removal :
Sunburn or Heavy / Direct Sun Exposure :
Tanning Bed Exposure :
Laser Procedure(s) ?
Microdermabrasion :
Do you have a tendency toward redness, rash or hives?
Injectable(s) in the last 30 days (Botox etc. or fillers) :

Are you taking / using any of the following:

 

I hereby certify that the above information is true and correct to the best of my knowledge and that I am the above-named patient or the duly authorized general agent of the above-named patient, authorized to furnish the information requested, and seek and authorize health care services. I understand that it is my responsibility to find out what my insurance coverage options are with my insurance company. I further understand that Gem State Dermatology (GSD) will assist me in obtaining authorization if necessary, however, ultimately it is my responsibility as the patient to determine if a prior authorization is required. I authorize GSD to furnish medical records and any other information necessary to process and obtain payment from my insurance company. This information may be released to my primary care physician and, upon request, to any other healthcare provider who may need the information for continuity of care. This release of information will remain in effect until revoked by me in writing. I understand and agree that I am responsible for payment of all charges including those not paid by my insurance in a reasonable time. I hereby assign all applicable benefits and direct that payment be made directly to Gem State Dermatology, PA for all services provided to/for me during my visits. I acknowledge that photo IDs taken are used to assist in patient recognition per HIPPA guidelines. Any patient that does not show for their scheduled office visit appointment and does not call within 24 hours to cancel or to reschedule, will receive a $25.00 charge. As required by law, I have been given the opportunity to read the notice describing information about privacy practices followed by GSD and I acknowledge the receipt of a copy of GSD’s Notice of Privacy Policy.


When the form has been sent successfully you will see a page that says "Thanks!"