New Patient Forms Please enable JavaScript in your browser to complete this form. - Step 1 of 3Health HistoryName *FirstMiddleLastDate *Who referred you to Dr. Comite?Briefly describe your skin problem or reason for appointment:Current Treatment:Past Treatment:Are you taking any medications for any reason? If yes, please specify:AntacidsAntibioticsAntihistaminesAntidepressantsAspirin, Bufferin, Advil, etc.Birth Control PillsBlood ThinnerBlood Pressure PillsCortisone/SteroidsCough MedicineDigitalisDilantinHormonesInsulin/DiabeticIron Poor MedicationLaxativesInjectionsSleeping MedicationThyroid MedicationTranquilizersVitaminsWater PillsWeight ReductionI DO NOT TAKE ANY MEDICINESOther Non-prescription Rx:Are you allergic to ANY MEDICINE? Please specify, including reaction:Do you have any other allergies? Please specify:Operations/Surgeries you have had (include year):Disease you have had requiring hospitalization (include year):Any serious illnesses NOT REQUIRING HOSPITALIZATION?Do you see any other type of doctor or specialist {i.e. Cardiologist, Allergist, Gynecologist, etc.}? Please specify names of Doctors:NextPatient InformationName *FirstMiddleLastDate of Birth *Multiple ChoiceMaleFemaleMinorSocial Security # *Marital Status: *SingleMarriedWidowDivorcedPartnerHome Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeHome Phone:Cell Phone: *Work PhoneI give my permission to leave detailed messages on my phone: *YesNoWhat phone do you prefer for messages?HomeCellWorkEmail *Employer (Name, Address, Occupation/Job Title)Name of Family Doctor:Family Doctor Phone #:Primary Insurance Company: *Subscriber Name and DOB: *Insurance ID (Policy #): *Group #: *Secondary Insurance Company:Subscriber Name and DOB:Secondary Insurance ID (Policy #):Secondary Group #:Responsible Person (if under 18):FirstMiddleLastRelationship to Patient:Address (If different from above):Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeTelephone Numbers (If different from above):NextCancellation & Missed Appointment Policy Our office considers an appointment to be a commitment and an agreement. When an appointment is scheduled, the doctor and staff time is set aside for you. Unlike other practices, we do not double or triple book patients. Therefore, we must charge a fee for all appointments not cancelled two weeks in advance. In today’s busy world, unplanned issues arise for all of us. However, we politely request that appointments, which you are unable to honor, are appropriately cancelled so that we may offer them to a patient on our waiting list. Cancelled Appointments: No charge will be made for any appointment cancelled at least two weeks in advance. Missed Appointments: A missed or cancelled medical appointment without two weeks notice will be billed a fee of $50.00. A missed or cancelled cosmetic appointment without two weeks notice will be billed a fee of $200.00 Exceptions: Same day cancellation because of serious medical/family emergency or dangerous road conditions (snow and ice) will not be charged as long as we are notified by telephone before the scheduled appointment time. I am aware of the Cancellations & Missed Appointment Policy and agree to the terms.Date *Submit