oaklandhillsdermatology.com - HISTORY & INTAKE

HISTORY & INTAKE
NAME:

First NameLast Name
MALEFEMALE
BIRTH DATE:

MonthDayYear
Date
SSN:
ADDRESS:

STREET ADDRESS

Street Address Line 2

CITYSTATE

ZIP
HOME PHONE:
Please enter a valid phone number.Format: (000) 000-0000.
CELL PHONE:
Please enter a valid phone number.Format: (000) 000-0000.
EMAIL ADDRESS:
example@example.com
PRIMARY CARE PHYSICIAN:
PHONE NUMBER:
Please enter a valid phone number.Format: (000) 000-0000.
HOW DID YOU HEAR ABOUT US?
RACE:
ETHNICITY:
MARITAL STATUS:
I Give Oakland Hills Dermatology to discuss my care with the following individual(s):
NAME:
PHONE:
Please enter a valid phone number.Format: (000) 000-0000.
RELATION TO PATIENT:
YESNO
NAME:
PHONE:
Please enter a valid phone number.Format: (000) 000-0000.
RELATION TO PATIENT:
YESNO
I DO NOT give Oakland Hills Dermatology to discuss my care with anyone but myself.
Patient/Guardian Signature:

Clear
Date:

MonthDayYear
Date
Need to send us your insurance information? You may email it to oaklandhillsreceptionist@gmail.com
Should be Empty: