_________________________________________________________________ has an appointment on

Monday Tuesday Wednesday Thursday Friday

Date: ___________________________________________ at ____________________________ AM/PM

Location:

With:

Please give at least 24 hour notice for any appointment changes to avoid a cancellation fee.

PLEASE ARRIVE 5 MINUTES PRIOR TO APPOINTMENT TIME NOTED ABOVE

Reminder: Patients under 18 years of age must be accompanied by a parent or guardian.

In order to ensure a prompt visit, we ask that you bring the following to your appointment:

• Completed Paperwork• Insurance Card• Photo ID• List of current medications• Office visit co-pay

If you have any questions about your appointment,please contact us at 559.439.3000.

Thank you!Boswell Dermatology Our two offices are located near Bullard and West, just

south of the Pavilion West Shopping Center.

5701 & 5709 N. West Ave559.439.3000

*Note: While skin cancer surgeries are primarily done at our Surgery Center at 5709 N. West Ave, general dermatology patients are also seen here.

5701 N. West Ave | Fresno, CA 93711559.439.3000 phone | 559.439.3004 fax 5709 N. West Ave | Fresno, CA 93711

559.439.3000 phone | 559.439.3004 fax

Welcome to Boswell DermatologyPlease note that our practice consists of two buildings in the same complex.

J. Scott Boswell, MD

Jared Lund, MD

Vivian Young, FNP

Kristie Cyrus, FNP

Jessica Krigbaum, FNP

Christina Stempson, FNP

Jordan Cutts, FNP

Lea Pisching, FNP

Brittney Stanley, FNP

Directions to Boswell Dermatology

Traveling South on 41: Take 41 South to the Bullard Ave exit and turn right on Bullard. Take Bullard to West Ave and turn left on West. Turn right into the third driveway, which is the Pavilion Professional center. Come up the driveway; we are the first building on the left. Traveling South on 99: Take 99 South to the Herndon Ave exit and turn left on Herndon. Take Herndon to West Ave and turn right on West Ave. Take West Ave and get into the right hand lane before crossing Bullard Ave. After crossing Bullard, turn right into the third driveway, which is the Pavilion Professional center. Come up the driveway; we are the first building on the left. Traveling North on 41: Take 41 North to the Bullard Ave exit and turn left on Bullard. Take Bullard to West Ave and turn left on West Ave. Turn right into the third driveway, which is the Pavilion Professional center. Come up the driveway; we are the first building on the left. Traveling North on 99: Take 99 North to the Herndon Ave exit and turn right on Herndon. Take Herndon Ave to West Ave and turn right on West Ave. Take West Ave and get in the right hand lane before crossing Bullard Ave. After crossing Bullard Ave, turn right into the third driveway, which is the Pavilion Professional center. Come up the driveway; we are the first building on the left.

PATIENTREGISTRATIONINFORMATIONPleasePRINTandcompleteALLsectionsbelow.

PERSONALINFORMATION Today’sDate:________________________MaritalStatus:□Single□Married□Divorced□Widowed Sex:□Male□FemaleName:____________________________________________________________________________________________LastNameFirstNameMiddleInitialMaidenName

StreetAddress:_______________________________________________City:_____________State:____Zip:_______HomePhone:()_________________________________CellPhone:()_________________________DateofBirth:_________/_________/_________SocialSecurityNumber:___________________________________EmailAddress:_____________________________________________________________________________________RESPONSIBLEPARTYINFORMATIONIfself,pleasecheckboxandgotoinsurancesectionbelow□Self□Spouse□Parent□Male□FemaleSpouse/ParentName:________________________________________DateofBirth:________/_________/_________BillingAddress:______________________________________City:____________________State:____Zip:_________HomePhone:()_________________________________CellPhone:()__________________________INSURANCEINFORMATIONPleasepresentallinsurancecardsandnotifyusofchangesininsurance

PrimaryInsurance SecondaryInsurancePrimaryInsurance:______________________________SecondaryInsurance:____________________________ID#:__________________________________________ID#:__________________________________________Group#:_______________________________________Group#:_______________________________________InsuredName:__________________________________InsuredName:__________________________________InsuredDOB:___________________________________InsuredDOB:___________________________________ PERSONALREPRESENTATIVEIauthorizethefollowingperson(s)toreceiveorknowinformationregardingmyhealthcare.Thisauthorizationmayberevokedinwritingatanytime.Name:_______________________________________________PhoneNumber:_______________________________Name:_______________________________________________PhoneNumber:_______________________________

• Iherebygiveconsentformedical/surgicaltreatmenttothecareproviderswithBoswellDermatology.• IacknowledgethatIwasprovidedwithacopyoftheNoticeofPrivacyPractices.Ihavereadandunderstandmyrights.• Iauthorizethereleaseofinformationtofacilitatetreatment,paymentorhealthcareoperations.

____________________________________________________Date:_________________________________________PatientSignature(orResponsiblePartySignature)

We’rehappythatyouhavechosenBoswellDermatology.Wearecommittedtoexcellenceinhelpingyoumeetyourhealthcareneedsandunderstandthatbilling/paymentforhealthcareservicescanbeaconfusingandsensitivetopic.Pleasetakethetimetoreviewthepoliciesofourpractice;wewillbehappytoansweranyquestionsyoumayhave.Pleaseinitialtoindicatethatyouhavereadeachpolicy____Insurance:Wearecontractedwithmanyinsurancecompaniesandwillgladlybillonyourbehalf.Itisthepatient’sresponsibilitytobesurethatwehavethecorrectinformationandthatwearein-networkwithyourinsurance.Patientsareresponsibleforco-payment,deductiblesandco-insurance.Allco-paymentsmustbepaidatyourappointmentperourcontractwithyourinsurance.Therewillbea$10feeaddedtoyourbillshouldyoufailtodoso.Ifyouhavequestionsregardingyourinsurance,pleasecallyourinsurancecompanysotheymayaddressyourquestions.____MEDI-CAL:WearenotcontractedwithanyMedi-Calplan.Wecannotaccept,norbill,theseplansunderanycircumstance.Furthermore,ifyouhaveoneoftheseplans,wewillnotbeabletoseeyouonacashbasis.TodosowouldjeopardizeyourhealthbenefitsandopenourofficetopenalizationbytheState.____Deductibles:Ifyouhavenotmetyourdeductible,itisourpolicytocollect,atthetimeofyourappointment,forservicesweknowwillnotbepaidbyyourinsurance.Wedonotguaranteethattheamountpaidatthetimeofservicesettlesyourbillwithus.____Non-CoveredServices:Pleasebeawarethattheremaybeservicesrenderedatyourappointmentthatarenotcoveredbyyourinsurance.Hairloss,skintags,andtheremovalofbenigngrowthsarecommonconditionsthatmaynotbepaidbyinsurancecompanies;youmayreceiveabillfromourofficefortheseservices.Pleasebeawarethatanythingexcisedfromyourbodywillbesentouttoadermatopathologistandyoumayreceiveaseparatebillfromthatoffice.____Referrals/Pre-Authorizations:Itisyourresponsibilitytoobtainacurrentreferral/pre-authorizationfortreatment,shouldyourinsurancedictatethatoneisnecessary.Intheabsenceoftheappropriatedocumentation,youagreetoacceptfullresponsibilityforthechargesrelatedtotreatment.____ProofofIdentification/ProofofInsurance:YouwillbeaskedtoprovideuswithacopyofyourIDandinsurancecardsforyourchart.Pleaseunderstandthatwearehelpingtoprotectyouridentityasapatient.WearealsorequiredtosendacopyofyourinsuranceandIDtopharmaciesforyourprescriptionsandacopymustaccompanyanypathologythatmaybesentoutfortesting.____Payment:Ifyoudonothaveinsuranceandwouldliketobeseen,weacceptcash,check,VISA,DiscoverorMasterCard;allpaymentsaredueatthetimeofyourappointment.A$25feewillbeaddedtoanycheckthatisreturnedforinsufficientfunds.Oncewehavereceivednotification/paymentfromyourinsurancecompany,wewillsendyouastatement.Allbalancesaredueuponreceiptofthestatement.Itisneverourintenttosendapatienttocollectionsfornon-payment;pleasecontactthebillingofficeifyouhaveanyquestionsregardingyourbill.____No-Show/LateCancellation/Surgeries:Weunderstandtheremaybetimeswhenyoumissanappointmentduetoillnessoremergencies.However,weaskthatyoucall24hourspriortoyourappointmenttomakechangesorcancelyourappointment.Pleaseunderstandthatbecauseappointmenttimeslotsarevaluable,youwillbechargeda$75noshow/latecancellationfeeifyoudonotgivea24hournotice.Thismustbepaidbeforeyouarescheduledforafuturevisit.Ifyouarescheduledforanysurgicalprocedure,werequirea72hournoticetocancelorreschedule.Youwillbechargeda$300feeifyoudonotgive72hournotice.____ConsenttoPhotograph:Wewillbeaskingpermissiontotakeyourphoto.Pleaseunderstandthatthisistobeusedforidentificationpurposesandwillaidusinkeepingtrackofareasofconcernforfuturetreatment.WeWILLNOTpublishyourphotoswithoutyourpermission.Ifaproviderwouldliketouseaphototobeusedformedicaleducation,youwillbeaskedtosignaseparateconsentformtodoso.

• IhavereadthepoliciessetforthbyBoswellDermatology.Mysignaturebelowsignifiesmyunderstandingandwillingnesstocomplywithyourpolicies.

____________________________________________________Date:_________________________________________PatientSignature(orResponsiblePartySignature)

NEWPATIENTMEDICALHISTORYName:___________________________________________________________Date:______________Age:__________Howwereyoureferredtoourclinic?Physician(fullname):Dr.______________________________________________________________________________

Didthesamerequestingphysicianseeyouforyourskincondition?□Yes□NoFriend(name):_____________________________________Other(pleasespecify):______________________________PharmacyName:__________________________________________________Phone:____________________________

MedicalHistory:Inyourownwords,pleasestatethereasonforyourvisit(chiefcomplaint):______________________________________________________________________________________________________________________________________________________________________________________________________________________________Howlonghaveyouhadthisproblem?(duration)___________________________________________________________

Whatpartsofyourbodyareaffected?(location)___________________________________________________________

Whatmakesitbetter?Whatmakesitworse?(changeinseverity)________________________________________________________________________________________________________________________________________________Howdoesthisproblembotheryou?(symptoms)___________________________________________________________

Whattreatmentshaveyoureceivedforthisproblem?(previoustherapy)_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Isyourproblem□worsening?□stable?□improving?(timing)Explain:_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Pastmedical/family/socialhistory:Pleaselistallpastmajorillnessesandoperations:___________________________________________________________________________________________________________________________________________________________________________________________________________________________________Pleaselistallmedicationsyouarecurrentlytaking:____________________________________________________________________________________________________________________________________________________________Pleaselistalldrugandenvironmentalallergies:_______________________________________________________________________________________________________________________________________________________________Isthereafamilyhistoryofaconditionsimilartoyours? □Yes□NoAdditionalInformation:_________________________________________________________________________________________________________________________Isthereafamilyhistoryof(pleasemarkthesquare(s)thatapply):□adultacne□asthma□diabetes□eczema□hayfever□geneticdisease□hairloss□melanoma□psoriasis□skincancerAdditionalinformation:_______________________________________________________________________________

Occupation:_________________________________________________________________________________________Doyousmoke?□Yes□NoDoyoudrinkalcohol?□Yes□No

CosmeticConcerns:Wouldyoubeinterestedinanti-aging/wrinkletreatment?□Yes□NoWouldyouconsiderBotox/Juvédermfiller?□Yes□NoAreyouinterestedinlaserhairremoval?□Yes□No

ReviewofSymptomsSkin:Haveyouseenadoctorforotherskinproblems?□Yes□NoWhichone(s)?_________________________________________________________________________________________________________________________________Doyouhave(pleasemarksquare(s)thatapply:□hairloss□skincancer□abnormalmolesWhenyouareexposedtosunlight,doyou:

1.□Alwaysburn 2.□Usuallyburn,rarelytan3.□Oftenburn,tanslowly 4.□Sometimesburn,tanwell5.□Rarelyburn,alwaystan 6.□Neverburn,deeplytan

Women:Areyoupregnant? □Yes□No Doyouplantobecomepregnant? □Yes□NoAreyounursing? □Yes□No Doyouhavebreastproblems? □Yes□NoMarksquarenexttoanysymptomorconditionyouarehaving: General Gastrointestinal Neurologic□fever □liverdisease □epilepsy/seizures□chills □intestinaldisease □headaches□weightloss □heartburn/indigestion □stroke□lossofappetite □abdominal/stomachpain □dizziness□fatigue □diarrhea □disorientation □constipation □confusionHead,Eyes,Ears,Nose,Throat □bloodinstool/blackstool □memoryloss□visualproblems □rectalpain □numbness□dryeyes □nausea □doublevision□eyedisease □vomiting □lossofconsciousness□ringinginears□eardisease Genitourinary Psychiatric□bloodynose □kidneydisease □nervousbreakdown□stuffynose □bladderdisease □depression□swallowingdifficulties □bloodinurine/darkurine □insomnia□drymouth □femaleproblems □soremouth □stillbirth/spontaneousabortion Endocrine□mouthulcers □problemswithurination □diabetes □enlargedglandsCardiovascular Musculoskeletal □hormonalproblems□pacemaker □jointaches □thyroiddisease□heartdisease □swollenjoints □mitralvalveprolapse □muscleaches Hematologic/Lymphatic□hypertension □muscleweakness □anemia□chestpain □backpain □freebleedingtendency □ankleswellingRespiratory □fingerssensitivetocold Immunologic□cough □immunedeficiency□difficultybreathing □frequentinfections□lungdisease□tuberculosis□coughingupblood

Ifneeded,pleaseelaborateonanyoftheabove:_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Date:_________________________________________PatientSignature(orResponsiblePartySignature)

NOTICEOFPRIVACYPRACTICESACKNOWLEDGEMENTFORM

THENOTICEOFPRIVACYPRACTICEDESCRIBESHOWMEDICALINFORMATIONABOUTYOUMAYBEUSEDANDDISCLOSEDANDHOWYOUCANGETACCESSTOTHISINFORMATION.PLEASEREVIEWITCAREFULLY,ASITEXPLAINS:

• Howthisofficewilluseanddiscloseyourprotectedhealthinformation.• Yourprivacyrightswithregardtoyourprotectedhealthinformation.• Thisoffice’sobligationsconcerningtheuseanddisclosureofyourprotectedhealth

information.IacknowledgethatIhavereceivedacopyoftheofficeNoticeofPrivacyPractices.IfurtheracknowledgethattheofficeNoticeofPrivacyPracticesisavailableatthefrontdeskuponrequest._____________________________________________________ _____________________PatientorPatientRepresentativeSignature Date_____________________________________________________PatientorPatientRepresentativePrintedName

5701 N. West Ave│Fresno, CA 93711 559.439.3000 phone│559.439.3004 fax

PathologyServices:Pleasenotethatyoumayhaveaskinbiopsydoneduringyourvisit,oronsubsequentvisits,hereatouroffice.Thesafeandstandardpracticeofmedicineistosendyourskinspecimentoapathologist(atypeofdoctor)forinterpretation.Tokeepinlinewiththestandardofcare,andbecausewehaveyourhealthinourbestinterests,wemustsendthespecimentomeetthehighlevelofcareyoudeserve.Yourbiopsywillbeinterpretedbyaboardcertifieddermatopathologist,whoarephysicianswhospecializeinmicroscopicdiagnosisofskindisorders.Thepathologistwhoevaluatesyourbiopsywillissueareporttoourofficelistingthemicroscopicfindingsalongwithadiagnosis.Wecustomarilysendspecimenstooneofthefollowingpathologylaboratories:CompassDermatopathology,Inc. UniversityofCA,SanFrancisco(UCSF)Dermatopathology6605NancyRidge 1701DivisaderoStreet,Room280SanDiego,CA92121 SanFrancisco,CA94115Telephone:858900-2700 Telephone:800497-0244BillingContact:SashaLepes,858900-2712 BillingContact:PacoDeAsis,415353-7270 PathologyAssociates 305ParkCreekDrive Clovis,CA93611 Telephone:559326-2800 Therearemanydifferentinsuranceplansofvaryingcoverageandcomplexities,soitisimpossibleforustoknowtheanticipatedchargesorcoverageyourparticularplanwillhavewitheachpathologylab.Therefore,beforeyourvisitwehighlyrecommendthatyoucallyourinsurancecompanytoseewhichoftheabovepathologygroupsiscoveredbyyourinsurance,andwhatyouranticipatedcostwillbeforapathologyreadofyourskinspecimen.Thiswillavoidsurprisesandunexpectedbillsonyourend.Ifyouhaveabiopsydoneduringyourvisit,pleaseletourstaffknowwhichpathologylaboratoryaboveispreferred.Ifyoudonotspecifywhichlaboratoryyouwouldlikeustouse,bydefaultwewillgenerallyuseCompassDermatopathology,Inc.orUCSFDermatopathology.LaboratoryServices:Youmaybesentforbloodworkaftervisitsatouroffice.Ifthisoccurs,youwillbegivenaQuestDiagnosticslaborderform.Werecommendyoucallyourinsuranceandconfirmwhichlocallaboratory(QuestDiagnostics,LabCorp,CommunityMedicalCenter,St.Agnes,etc.)iscoveredbeforegoingforbloodwork.Thiswillavoidsurprisesandunexpectedbillsonyourend.ImagingServices:Youmaybesentforimaging(X-rays,CTscans,MRI's)aftervisitsatouroffice.Ifthisoccurs,youwillbegivenanimagingorderform.Werecommendyoucallyourinsuranceandconfirmwhichimagingfacility(CaliforniaImaging,AdvancedMedicalImaging,CommunityMedicalCenter,St.Agnes,etc.)iscoveredbeforegoingforyourimagingtest.Thiswillavoidsurprisesandunexpectedbillsonyourend.

Iacknowledgetheinformationpresentedaboveregardingpathology,laboratoryandimagingservices.

___________________________________________ ____________________Name: Date