Joel A. Sabean, M.D. Dermatology Center of Southern Maine

NEW PATIENT

INFORMATION

PATIENT NAME
Last:	M.I.	First:

BILLING ADDRESS
Street:
City:	State:	Zip:
E-mail Address:		Phone:

PERSONAL INFORMATION
Social Security Number:	Marital Status:	Sex:

Birth Date:

Responsible Party (if minor):

EMPLOYMENT INFORMATION
Employer:		Address:
City:	State:	Zip:
Work Phone:

MEDICAL INFORMATION

Purpose Of Visit:

Known Medical Conditions:

Medications:

Allergies:

Allergies to medications:

Referring Physician's Name:

Address:

ADDITIONAL INFORMATION

Additional History

Please take a few moments to add any additional information or history about your problem and concerns:

Please list any questions or concerns you would like addressed during your visit that may not be related to your primary problem:

If you are on a number of medications for different health problems, please list what they are and what problem the medications are for:

	DRUG	PROBLEM
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INSURANCE INFORMATION

This office participates with: MPHMO, PHCH, BC/BS, HMO MAINE, TRICARE, HPH, HEALTHSOURCE, MEDICAL NETWORKS, AETNA, US HEALTH, MEDICARE, CIGNA Please provide us with an insurance identification card or cards we may copy.

At your request, we will provide an itemized statement of services rendered.

I UNDERSTAND THAT EVEN THOUGH I HAVE INSURANCE COVERAGE, I MAY BE RESPONSIBLE FOR PAYMENT. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE:

I authorize the release of any medical information necessary to process this claim. I also authorize my insurance company to make payments directly to Dr. Sabean.