Health History

Name *

First

Middle

Last

Date *

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:

Antacids
Antibiotics
Antihistamines
Antidepressants
Aspirin, Bufferin, Advil, etc.
Birth Control Pills
Blood Thinner
Blood Pressure Pills
Cortisone/Steroids
Cough Medicine
Digitalis
Dilantin
Hormones
Insulin/Diabetic
Iron Poor Medication
Laxatives
Injections
Sleeping Medication
Thyroid Medication
Tranquilizers
Vitamins
Water Pills
Weight Reduction
I DO NOT TAKE ANY MEDICINES

Other 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:

Patient Information

Name *

First

Middle

Last

Date of Birth *

Multiple Choice

Male
Female
Minor

Social Security # *

Marital Status: *

Single
Married
Widow
Divorced
Partner

Home Address *

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone:

Cell Phone: *

Work Phone

I give my permission to leave detailed messages on my phone: *

What phone do you prefer for messages?

Home
Cell
Work

Email *

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):

First

Middle

Last

Relationship to Patient:

Address (If different from above):

Address Line 1

Address Line 2

City

State

Zip Code

Telephone Numbers (If different from above):

Patient or Guardian Signature: *

Cancellation & 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.

Patient Signature or Parent or Guardian *

Date *

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