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Patient Registration

FOR NEW REGISTRATION ONLY - IF YOU HAVE ALREADY REGISTERED, CLICK HERE.

Complete the form below to register. Incomplete registrations may not contain enough information for us to with in scheduling your appointments, so please answer the questions completely and carefully...Thank you!

Note: This form should be used ONLY FOR NON-URGENT appointments.

Special considerations are given to internet made appointments. Inquire about these considerations when you arrive for your appointment.

If you have an urgent medical problem that needs to addressed today, PLEASE CALL THE OFFICE

All information on this form and in the other appointment pages is confidential. We DO NOT share your information with anyone, period. ALL information in this area is encrypted using our secure server.

* Required Field
Patient Type New  Returning
Office Main  Pearland
Appointment Time
Appointment Date
Last Name: *
First Name: *
Middle Name:
Date of birth: *
MM/DD/YYYY
Gender:
Male
Female
Social Security Number:
Mailing Address: *
City: *
State: *
Zip: *
Home Phone: *
Work Phone/Extension:
Cell Phone
Alternate Phone
Reason for Visit
Referred By
 
Person completing this form if other than patient:
Name:
Relationship:
 
E-mail:    (At least one e-mail address is required)
Note: NO sensitive information will be revealed in any e-mail.
Home E-mail:
Work E-mail:
I prefer to receive e-mail at:
Home
Work
Both
 
Responsible Party Information:
Insurance company:
Insurance Company's Address:
Plan ID#:
Group #:
Employer/Insurance company name:
Phone:
Name of insured:
Insurance Address:
Relationship to patient:
Self
Spouse
Dependent
Other:
 
(Specify)
Insured social security #:
Insured date of birth:
MM/DD/YYYY
 
Emergency Contact Information:
Person to contact:
Phone:
Alternate phone:
 
Please tell us how you heard of us:
Where did you hear about Dr. Milton Moore or Moore Unique Dermatology & Spa?:
Physician
Friend
TV
Radio
Print Ad
Internet
Other    (Please provide details below)
   
Please provide details, if possible:
 
 
Medical History
Are you allergic to any medications or anesthetics (i.e. lidocaine)? Yes  No
if Yes Please List
1.
2.
List all medication you are currently taking (including herbal/natural products/vitamins:
1.
2.
3.
4.
Dermatology Brand name medications are often more effective than Generic medications. Do you prefer to use?
Brand name medication only
Generic medications if equally effective
3. Generics whenever possible
Do you now have or have you ever had any of the medical conditions listed below?
High Blood Pressure Yes  No
Diabetes Yes  No
Thyroid Yes  No
Arthritis Yes  No
Heart Disease Yes  No
Kidney problems Yes  No
Bowel/Stomach Yes  No
Liver problems Yes  No
Joint problems Yes  No
Lupus Yes  No
Seizures Yes  No
Fainting Yes  No
Bleeding disorder Yes  No
Anemia Yes  No
Hepatitis A or B Yes  No
Hepatitis C Yes  No
HIV + Yes  No
With Sun exposure do you? Tan only  Tan and Burn  Burn
History of skin cancer? Yes  No
Precancers? Yes  No
Melanoma? Yes  No
Family History of skin cancer? Yes  No
Any specific skin problem? Yes  No
if Yes Please List
 
Abnormal problems with healing? Yes  No
Abnormal scars (Keloid) after surgery? Yes  No
Bleeding disorder: Yes  No
Do you develop skin rashes/reactions to? Medication  Food  Environment
(Women) Are you pregnant? Yes  No
(Women) Are you breast feeding? Yes  No
List any other disease or condition we should know about:
List surgical procedures you have had in the last 6 months:
Cosmetic Procedures:
Have you had or are you interested in information about these procedures or products?
Botox Have Had  Interested
Microdermabrasion Have Had  Interested
Collagen Have Had  Interested
Spider Vein treatment Have Had  Interested
Chemical Peels Have Had  Interested
Cosmetic skin care products Have Had  Interested
Facials or other aesthetic services have had Have Had  Interested
Social History
Do you smoke? Yes  No   If yes, how much?
Do you Drink Alcohol? Yes  No   If yes, how much?
Do you Use IV Drugs? Yes  No  If yes, what? how much?
Are you HIV Positive? Yes  No
Are you a healthcare worker? Yes  No
User Login:
E-mail Address:
(To be used when returning for additional appointments)		 *
Password: *
 
 

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