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Carr Dermatology

Patient Questionnaire


  Last name

  Mid name

  First name
*Birthday:
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:
Name:
Phone #:
()- -
Name:
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
*Signature:
Date:
(Your digital signature (full name) is as legally binding as a physical signature.)