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Carr Dermatology

Patient Questionnaire

  Last name

  Mid name

  First name

1. Please list the family members or other persons, if any, whom we may inform about your general medical condition and your diagnosis (including treatment, payment, and health care operation):
1 4
2 5
3 6
2. Please list the family members or significant others, if any, whom we may inform about your medical condition only in an Emergency:
Phone #:
()- -
Phone #:
()- -
3. Please print the address of where you would like your billing statements and/ or correspondence from our office to be sent if other than your home.
4. Please indicate if you want all correspondence from our office sent in a sealed envelope marked “confidential” Yes No
5. Please print the telephone number where you want to receive calls about your appointments, lab and x-ray results, or other health care information if other than your home phone number:
Phone #:
()- -
* I am fully aware that a cell phone is not a secure and private line.
6. Can confidential messages (i.e., appointment reminders) be left on your telephone answering machine, email or voicemail? Yes No

(Your digital signature (full name) is as legally binding as a physical signature.)