[PDF] BHS Dermatology Associates - Clarion Hospital

39430_7WELCOME_PACKET_Butler_32119.pdf David A. Cowan, MD Rebecca G. Pomerantz, MD Lisa L. Ellis, PA-C Sheri L. Rolewski, CRNP Kelly Valasek, PA-C

We are pleased that you have chosen our practice for your dermatologic needs. Our goal is to provide the

h ighest quality of care for your general, medical, and cosmetic dermatology needs.

Please complete this entire Welcome Packet

5 (five) days

prior to your scheduled office visit, and

forward these completed forms to our office via mail, fax or personal delivery. If this Welcome Packet is not

received 5 (five) days prior to your appointment this may result in the Provider requesting you to reschedule

your appointment.

If you have been referred to our office by another doctor please have your records sent to our office before

your scheduled appointment. Your records can be faxed to our office at

724-482-2212.

We accept

most insurance plans and will be happy to help you determine if we participate with your

insurance. If your insurance requires a referral it is your responsibility to obtain that referral and confirm that

our office has received your referral prior to your scheduled appointment.

Many insurance plans require that we obtain authorization for procedures performed in our office including

biopsies, cryotherapy, and injections. We will do our best to minimize additional trips to our office, but you

may be required to return to the office to have a procedure performed after your initial consultation.

For your appointment please bring:

1. A list of your current Medications including Over the Counter Medications 2. Your Insurance Card 3. Your Photo Identification 4 .

Your Recent Lab or Pathology Results

Our policies are as follows:

1. Your co-pay is due when you arrive for your scheduled appointment. 2.

Your completed Welcome Packet is to arrive in our office 5 days prior to your scheduled appointment.

3. Cancellation policy: Please provide at least a 48 hour notice if you are not able to arrive at your

scheduled appointment. We will reschedule your appointment promptly.

* You may be charged a $25 cancellation fee if you fail to provide a 48 hour notice to our office.

4 .

If you arrive late for your scheduled appointment you may be asked to reschedule your appointment.

Plea se do not hesitate to call our office with any questions at 1 -877-661-3376 BHS Dermatology Associates Benbrook Medical Center 300 NorthPointe Circle 102 Technology Drive Suite 230/240 Suite 104

Butler, PA 16001 Seven Fields, PA 16046

BHSdermatology.org

Phone: 1-877-661-3376 Fax: 724-482-2212 698

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WELCOME PACKET

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David A. Cowan, MD Rebecca G. Pomerantz, MD Lisa L. Ellis, PA-C Sheri L. Rolewski, CRNP Kelly Valasek, PA-C WELCOME PACKET

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Name: ___________________________

_______ ___________________ Email Address: ______________________________________________________

Social Security Number: _____________________________ Date of Birth:_____________________

Address: ____________________________

City:___________ State:_______

Zip Code: ______________

Telephone: _______________________________ Cell Phone: ____________________________________ Primary Care Physician: ___________________________________ City ____________________________

Emergency Contact: ________________________

____ Relationship to Patient: _____________________

Address: ________________________________

____ City: _____________ State: _______ Zip: _________

Home Phone: ___________________________

____ Cell Phone: __________________________________ I authorize the release of confidential medical information to the following contact persons:

Name: ___________________________________

____ Name: _______________________________________

Relationship: _____________________________

____ Relationship: _________________________________

Phone: ___________________________________

___ Phone: ______________________________________ Patient Signature: _____________________________________ Date: _______________________________

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Preferred Pharmacy Name: _____________________

_______ Pharmacy Telephone: ___________________ Pharmacy Address/Location: ___________________________ Pharmacy Fax: _________________ ________ PATIENT CONSENT FOR MEDICAL PHOTOGRAPHY and USE OF MEDICAL PHOTOGRAPHY

__ I hereby authorize Dr. David A. Cowan and other staff at BHS Dermatology Associates to utilize medical photography in my care

and consent to have photographs taken of the area(s) of the skin/body being examined and treated. Medical photography may include

still photography as well as video photography, or other images. I understand that the photographs will only be used to aid in diagnosis

and treatment plans, health care administration, and other uses specifically allowed by law. These photos will be kept on file in my

medical record and I will have access to these photos upon written request. Images taken before, during, and after medical and surgical

procedures may be included as part of my medical record. I understand that these photographs will not be printed, published, or

otherwise circulated without further consent. __ I do not authorize photographs to be taken during my visit

__ I hereby authorize Dr. David A. Cowan and representatives of BHS Dermatology Associates to use the photographs within my

medical record for purposes of medical education and teaching , for publication in medical textbooks and journals, and for marketing

and advertising in print or on the BHS Dermatology Website. These photographs will not be sold at any time to a third party. My name

will not be identified and every effort will be made to limit the ability of others to identify me in pictures. By giving consent to Dr. David

A. Cowan and all representatives

and staff of BHS Dermatology to use my medical photographs, I understand that I will not receive

payment from any party at any time. I hereby release and discharge Dr. David A. Cowan, BHS Dermatology Associates, and their

employees, trustees and offices from any claims, demands, or legal actions for use of these images from my medical record.

__ I do not authorize the use of my photographs from my medical record for purposes of medical education and teaching

Patient Signature: ____________________________

______________________ Date: ________________ Time: _______________ OR

Patient Representative: _____________________________________________ Date: ________________ Time: _______________

698

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David A. Cowan, MD Rebecca G. Pomerantz, MD Lisa L. Ellis, PA-C Sheri L. Rolewski, CRNP Kelly Valasek, PA-C HEALTH HISTORY

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Patient Name:

___________________________ Date of Birth: _________ _Today's Date:___________

What is the reason for your visit today?

____________________________________________ _______ When did you notice it? _________________ Symptoms: _____________________________________

Referred by: _______________________________

______ MEDICAL HISTORY: Please check all that apply - Past or Present

SKIN CANCER: None

Malignant Melanoma Basal Cell Carcinoma Squamous Cell Carcinoma Other Cancer(s) (Please List Types): ___________________________________________________________

If Skin Cancer: When treated and at what Facility: _________________________________________________

Acne Arthritis Asthma Colon/Intestinal Disorder

Bleeding, Excessive

Blood Clots Bruising Easily Headaches (chronic) Diabetes Eczema Hay Fever Herpes Zoster (Shingles)

Heart Problems

Hepatitis Herpes Simplex (cold sores) Kidney Disease High Blood Pressure HIV/AIDS Infections (chronic) Lupus Liver Disease Loss of Skin Pigment Lung Disease Rheumatic Fever Mitral Valve Prolapse Pacemaker Psoriasis Thyroid Disease Scarring/Keloids Sexually Transmitted Disease Stroke Vitiligo Tuberculosis Ulcers, Skin Varicose Veins Warts Wound healing difficulty OTHER (Please list): _________________________________ * Females:

Chronic vaginal infections Taking oral contraceptives (list): _________________________________

Currently pregnant Possibly pregnant Breast Feeding Date of last menstrual period: _______________ Hysterectomy SURGICAL HISTORY: Type of Surgery and Date of Surgery

1. _________________________________________________________________________________________________

_________________________

2.______________________________________________________________________________________________

________________________ _____

HISTORY OF RADIATION TREATMENT: ŏŰġġġġġŚŦŴ ______________________________________________________________

CURRENT MEDICATIONS: LIST MEDICATIONS BELOW AND PLEASE ALSO BRING MEDICATION LIST TO YOUR APPOINTMENT

INCLUDE-Name of Medication-Strength (ie: 20mg-40 etc.) - Dose (Tablet-Capsule etc.) Frequency (1 a day etc)

1.____________________________________________________________ 6._________________________________________________________

2.____________________________________________________________ 7._________________________________________________________

3.____________________________________________________________ 8._________________________________________________________

4.____________________________________________________________ 9._________________________________________________________

5.____________________________________________________________ 10._________________________________________________________

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DRUG ALLERGIES: Please check and name the specific drug and if known list the type of reaction you experienced:

No Known Drug Allergies ___________________

Anesthetics________________________ Aspirin______________________ Lidocaine ____________________ Penicillin __________________________ Sulfa _______________________

Tetracycline

_________________________ Other drugs _________________________________________________________

TYPE OF REACTION: ____________________________________________________________________________________________

ARE YOU ALLERGIC TO

LATEX: No Yes Include Reaction _______________________________________________

NON-DRUG ALLERGIES: Include Reaction _____________________________________________________________________________________________________________________

DO YOU REQUIRE PRE-MEDICATION PRIOR TO SURGERY? No Yes

* Do you take Antibiotics prior to Dental Procedures, Surgeries or do you have a Heart Valve or Artificial Joint

(Describe)______________

____________________________________________________________________________________________________

SOCIAL HISTORY:

Do you use SUNSCREEN? Yes No If so SPF?: ________ Do you Tan in a Tanning Bed: Yes No

Do you drink ALCOHOL? Yes Never Quit If yes, how much? ___________How often? ______________ Do you use TOBACCO? Yes Never Quit How much per day? _____ How many years? _______ Do you use RECREATIONAL DRUGS? Yes Never Quit If yes, how much? _____ How many years? _____ OCCUPATION: ___________________________________________________ Working Retired Disabled Male Female Marital Status: Single Married Divorced Widowed Children: Yes No If yes, how many? _____________________________________ FAMILY HISTORY: (Please check all that apply and list family member)

Allergies ________________ Arthritis _________________ Asthma _______________Cancer _________________

Collagen Vascular Disorder Diabetes _______________ Eczema ______________________________ HayFever___________________ Lupus ___________________ Malignant Melanoma _____________ Psoriasis ___________________ Skin Cancer ____________ Tuberculosis _______________________

OTHER PERTINENT HISTORY:

1. _________________________________________________________________________________

2. _________________________________________________________________________________

Patient Signature: _____________________________________________________________________ Date/Time: ______________________________________

OR

Patient Representative: _______________________________________________________________ Date/Time: ______________________________________

Physician Signature: ___________________________________________________________________ Date/Time: ______________________________________

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PATIENT REQUEST FOR DISCLOSIN

G VERBAL INFORMATION

PATIENT NAME:_______________________________________________ DATE OF BIRTH:___________________

PRACTICE NAME:

BHS Dermatology Associates____________________________________________ I do /do not consent for detailed messages to be left on my voicemail.

Phone:_________________________________

Please list any person(s) whom you allow this office to discuss your medical care with (such as parents/spouse/

children, etc.)

Name:___________________

__________________Relationship:____________________ Phone ___________________

Name:_____________________________________Relationship:____________________ Phone ___________________

Name:_____________________________________Relationship:___________________ _ Phone ___________________

Name:_____________________________________Relationship:____________________ Phone ___________________

Special Instructions or Limitations

:________________________________________________________________________________________________

As an extra measure of security, before any member of our office staff will discuss any aspect of your care or information,

including but not limited to, appointment dates and times, test results, medication lists, etc., with you or any person listed

above, you or that person must know the unique password that you create with this office. Please choose any word that is easy

to remember for you and the listed members. For example: pet"s name, favorite vacation, favorite food, favorite color, etc.

Be sure to notify all person"s listed above of your password . Secure Password:_______________________________________________________________________ Password Hint:__________________________________________________________________________

We will continue to rely on the information on this form when communicating with you, family members, or others involved in

your care unless you request changes. Please promptly notify our office in writing if you wish to alter the designations abo

ve.

With my signature, I am aware that BMP Physician Division encompasses many different Physician Specialties within Butler

Health System. Any of those offices may have access to my medical records. _______________________________________________________ __________________ Signature of Patient/Legal Representative: Date/Time: Relationship to Patient:_________________________________________________________________ This authorization hereby revokes any previous authorizations. To revoke this authorization, please send a written request to our office.

Reviewed. No changes.

Initials______________ Date___________ Initials______________ Date___________

Initials______________ Date________

___ Initials______________ Date___________ BHS Dermatology Associates David A. Cowan, MD Suite 230 BHS Center for Dermatology Surgery David A. Cowan, MD Suite 240 Benbrook Medical Center 1 102 Technology Drive Butler, Pa 16001 * 422 Westbound - From Kittanning Pass Route 356 Lyndora/Butler Exit Turn Left on Greenwood Drive .5 Miles Bottom of the Hill - Right onto Benbrook Road (NOT Marked) 1.0 Miles Right onto Technology Drive .2 Miles Benbrook Medical Center 1 1 st

2 story Building on your Right

BHS Dermatology Associates - David A. Cowan, MD Second Floor - Suite 230 / Suite 240 *422 Eastbound - From New Castle Turn Right onto Greenwood Drive .5 Miles Bottom of the Hill - Right onto Benbrook Road (NOT Marked) 1.0 Miles Right onto Technology Drive .2 Miles Benbrook Medical Center 1 1 st

2 story Building on your Right

BHS Dermatology Associates - David A. Cowan, MD Second Floor - Suite 230 / Suite 240 *Arriving from Slippery Rock from Route 8 PA 8 Right onto South Benbrook Road 4.2 Miles Right onto Technology Drive .2 Miles Benbrook Medical Center 1 1 st

2 story Building on your Right

BHS Dermatology Associates - David A. Cowan, MD Second Floor - Suite 230 / Suite 240 *Arriving from Evans City / 79 / PA 68 PA Route 68 Left onto Benbrook Road .2 Miles Left onto Technology Drive .2 Miles Benbrook Medical Center 1 1 st

2 story Building on your Right

BHS Dermatology Associates - David A. Cowan, MD Second Floor - Suite 230 / Suite 240