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Home Dermatology Dermatology Index Acne Eczema Mohs Surgery Psoriasis Rosacea Skin Cancer Cosmetic Cosmetic Injectables Juvederm Kybella Botox Chemical Peels CoolSculpt CO2RE Intima Laser Hair Removal Microlaser Peel Microneedling Scar Treatments Sciton BBL Sclerotherapy SculpSure Microdermabrasion Wellness Resources New Patient Intake Forms After care DLS locations on O'ahu List of Blood Thinners Patient Portal Request Forms Wound Care Instructions About Philosophy Providers Accepted Insurances Current Specials FAQ Contact Information Store Book Appointment Book Appointment Telehealth Appointment Pay Bill Online

NEW PATIENT REGISTRATION FORM

Name *

First Name

Last Name

Date of Birth *

YYYY

Social Security Number

Gender *

Male

Female

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone

(###)

###

####

Mobile Phone

(###)

###

####

Work Phone

(###)

###

####

PCP/Referring Provider

Preferred Pharmacy

INFORMATION MAY BE RELEASED TO THE FOLLOWING FRIEND/FAMILY MEMBER

Name

First Name

Last Name

Phone Number

(###)

###

####

EMERGENCY CONTACT INFORMATION

Name

First Name

Last Name

Relationship to Patient

Phone Number

(###)

###

####

INSURANCE INFORMATION

Primary Insurance *

Insurance Type

Member ID Number *

Subscriber Name

Relationship to Patient

Subscriber Date of Birth

YYYY

Subscriber SSN

Secondary Insurance

Insurance Type

Member ID Number

Subscriber Name

Subscriber Date of Birth

YYYY

GUARANTER INFORMATION

(Person financially responsible for bills when patient is under 18 years old)

Guarantor Name

First Name

Last Name

Guarantor Date of Birth

YYYY

Guarantor Phone Number

(###)

###

####

Guarantor Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

TRICARE PATIENTS

Sponsers Benefits #

How Did You Hear About Us? *

Yelp

Google

Family/Friend

Other

PATIENT MEDICAL HISTORY

Past Medical History *

(check all that apply)

Anxiety

Artificial Heart Valve

Artificial Joint

Asthma

Cancer

Diabetes

Depression

Hepatitis

High Blood Pressure

HIV+/AIDS

Organ Transplant

Pacemaker/Defibrillator

Radiation Treatment

Seizures

Thyroid Problems

NONE

Other Health Conditions

Past Surgeries

Skin History *

(check all that apply)

Actinic Keratosis

Basal Cell Carcinoma

Blistering Sunburn

Cold Sore/Oral Herpes

Difficulty Stopping Bleeding

Ezcema

Fainting with Procedures

Hayfever/Allergies

Keloid Scarring

Melanoma

Precancerous Moles

Psoriasis

Reaction to Local Anesthetic

Squamous Cell Carcinoma

NONE

GENERAL SKIN QUESTIONS

Do You Wear Sunscreen?

YES

History of Tanning Bed Use?

YES

Personal history of Melanoma? *

YES

Family History of Melanoma *

YES

Medications

(Prescriptions, Supplements, Vitamins)

Allergies/Medication Allergies

Latex Allergy

YES

Are you a smoker? *

YES

FORMER SMOKER

PATIENTS AGE 65+

Have you had your pneumonia vaccine?

YES

Have you established an advanced care plan?

YES

FINANCIAL OFFICE POLICY AND CONSENT

Basic Policy: Payment for service is due in full at the time the services are provided. For patients with insurance: Co payments are due at the time of service. Returned Check Policy: There will be a $40.00 fee for a check returned by the bank for any reason. Missed Appointments: I understand that if my appointment is canceled without a 24 hour notice or if it is deemed a no show I will be charged a $50.00 fee. I also understand that repeated occurrences may result in release from this practice. Account Payments: I understand that any balance due that is not paid within 60 days may be turned over to a collection agency and may increase for any recovery fees incurred by his process. Authorization and Release: I request that payment of authorized insurance benefits be made on my behalf to Kailua Dermatology Centers of Hawaii, LLC for any services rendered to me. I hereby agree to pay any and all charges that are not covered by insurance. I authorize the release of my medical information to my insurance company or Worker’s Compensation carrier that is necessary to determine benefits or the benefits payable for related services. Privacy Practices Acknowledgment: I have received and reviewed the privacy practices.

E-Signature *

INFORMATION EXCHANGE

Community Exchange: I authorize Kailua Dermatology Centers of Hawaii, LLC to use any means of electronic transmission to any Healthcare Professional, Hospital or Healthcare Facility to exchange my Protected Health information. Medication History: I authorize Kailua Dermatology Centers of Hawaii, LLC to obtain my Medical History from our eprescribe clearinghouse. The Medication History will include Medications prescribed by all Healthcare Providers. Patient Referral: I authorize Kailua Dermatology Centers of Hawaii, LLC to provide an electronic health record for each transition of care to another setting of care ( hospital, ambulatory primary care practice, ambulatory specialty care practice, long-term care. Home health, and rehabilitation facility) or provider of care or refer their patient to another provider. Your signature below signifies your understanding and willingness to comply with the above policy and consent to the community exchange, immunization registry, medication history, and patient referral as described above.

E-Signature *

HAWAII PRIVACY OF HEALTHCARE INFORMATION ON LAW NOTICES OR PRIVACY PRACTICES

This notice describes how medical information about you may be used and disclosed and how you can get access to this invoice. Please review it. Use and disclosures: We will use and disclose elements of your protected health information (PHI) in the following ways without your signed authorization. • Continuation of care by a specialist or another doctor • Release of information to your health plan for payment • Payment to physicians and hospitals who provide you with health care services • When release is required by law, including in judicial settings and to health oversight agencies and law enforcement In emergency situations or to avert serious health/safety situations • To medical examiners, coroners or funeral directors to aid in identifying you or to help them in performing their duties to organ, tissue and other donation organizations • To contact you about appointment reminders, treatment alternatives and other health related benefits and services • All other uses and disclosure by us will require us to obtain from you a written authorization in addition to any other permission you will provide us Your Rights: You have the following rights concerning your PHI: • To inspect and request copies of your medical records or appeal any denial of your request for inspection or copying • To request that your health care provider append information to your medical record • To receive correspondence of confidential information by alternate means or location • To receive an accounting of the disclosures by us of your PHI • To get updates or reissue of this notice, at your request • To complain to us or the U.S. Dept. of Health & Human Services if you feel your privacy rights have been violated How you can inspect, obtain copies of and/or amend your medical record: • If you wish to obtain copies of your medical records, send a written request to this office and you will be provided a full copy within 30 days • If you wish to attach information to improve the accuracy of completeness of your medical record, submit your request in writing to this office and this office and this information will be attached to your record. None of the digital records may be destroyed or erased. We are required by law to maintain the privacy of your PHI. We must abide by the terms of this notice or any update of this notice.

E-Signature *

PATIENT CONSENT FOR MEDICAL PHOTOGRAPHY

I consent for the medical photographs to be made of me or my child (or person whom I am legal guardian). I understand that the information may be used in my medical record, for purposes of medical teaching, or for publication in medical textbooks or journals as I have designated below. By consenting to these medical photographs I understand that I will not receive payment from any party. Refusal to consent to photographs will in no way affect the medical care I will receive. If I have any questions or wish to withdraw my consent in the future I may contact Kailua Dermatology Center of Hawaii, LLC. Please sign below one of the following options.

I consent for these photographs to be used in medical publications. I understand that the material will be published without my name attached. Every effort will be made to ensure I cannot be identified, but my complete anonymity cannot be guaranteed.

I agree to use of these photographs for medical records only.

Date *

YYYY

Thank you!

Location:
Hawaiian Islands Dermatology
1051 Keolu Drive, #107
Kailua, Hawaii 96734
Email: info@hidermatology.com

Phone: 808-263-3233
Fax: 808-263-3220

Hours:
Mon: 8:30am-5:00pm/ Lunch 12pm-1pm
Tues: 9:00am-7:00pm/ Lunch 1pm-2pm
Wed: 8:00am-4:30pm/ Lunch 12pm-1pm
Thurs: 9:00am-7:00pm/ Lunch 1pm-2pm
Fri: 8:00am-4:30pm/ Lunch 12pm-1pm
Sat: Closed
Sun: Closed

Hawaiian Islands Dermatology

1051 Keolu Drive, Suite 107,

Kailua, HI 96734,

United States

808-263-3233 info@hidermatology.com

Hours

Mon 8:30am to 5:00pm

Tue 9:00am to 7:00pm

Wed 8:00am to 4:00pm

Thu 9:00am to 7:00pm

Fri 8:00am to 4:30pm

Sat Closed

Sun Closed