Clear Dermatology
Patient Registration and Health Questionnaire

Sex


Preferred Number
May we leave a detailed message?
May we text appointment reminders?

May we email appointment reminders?
Would you like to be notified of promotions and events?

CONSENT TO DISCUSS CARE. If you are 18 years or older we cannot discuss your care with other family members, spouses or caretakers without your consent. Do you authorize consent for any other individuals?
If yes:

Ethnic Group
Race

Past Medical History
 
Skin Disease History
 

History of Skin Cancer
 LocationYear
Basal Cell:
Melanoma:
Squamous cell:
Unknown:
Other:
Do you wear Sunscreen? *
 
Do you tan in a tanning salon? *
Do you have a family history of melanoma? *
 
Cigarette Smoking *
Alcohol Use *
Do you have any of the following?
Alerts


Would you like information on any of the following:
All information entered into this form is transmitted through a secure network directly to our office and becomes protected health information.