New Patient FormName* First Last Social Security Number*Date of Birth* MM DD YYYYGender*MaleFemalePreferred Language*Marital Status*SingleMarriedDivorcedWidowedRace*CaucasianAmerican IndianAlaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderOtherEthnic Group*Hispanic or LatinoNot Hispanic or LatinoUnknownAddress* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneWork PhoneCell PhoneE-mail Address* Employment*Employed Full-TimeEmployed Part-TimeSelf-employedNot employed but looking for workNot employed and not looking for workHomemakerRetiredStudentPrefer Not to AnswerOccupation*Name of Parent/Emergency Contact*Relationship to PatientEmergency Phone NumberReferred By*NonePhysicianPatientFriendPlease list the name of the referrer:*Patient HistoryPlease indicate your key skin concerns and corresponding body area.* Acne scarring Acne/breakouts Abnormal scarring Blotchiness/redness Dryness Eczema Fine lines/wrinkles Hair loss/thinning hair Laxity/loss of volume Pigmentation Rash Rough, uneven texture Psoriasis Skin cancer Unwanted hair Moles/abnormal skin growth Spider veins/vascular abnormality Submental fullness “double chin” Underarm perspiration Stubborn/Unwanted Fat Other (please specify)Body area for: Acne scarringBody area for: Acne/breakoutsBody area for: Abnormal scarringBody area for: Blotchiness/rednessBody area for: DrynessBody area for: EczemaBody area for: Fine lines/wrinklesBody area for: Hair loss/thinning hairBody area for: Laxity/loss of volumeBody area for: PigmentationBody area for: RashBody area for: Rough, uneven textureBody area for: PsoriasisBody area for: Skin cancerBody area for: Unwanted hairBody area for: Moles/abnormal skin growthBody area for: Spider veins/vascular abnormalityBody area for: Submental fullness “double chin”Body area for: Underarm perspirationBody area for: Stubborn/Unwanted FatMore Details (for Other Skin Concerns)Please list any current or past medical conditions including any surgeries.*Please list any upcoming medical procedures including dental work.*Please indicate which, if any, cosmetic treatments you have done in the past. Be sure to include date of the last treatment and your level of satisfaction with results.* Microdermabrasion Botox Dermal fillers IPL Laser hair removal Cosmetic surgery Photorejuvenating laser (*list which type) Skin tightening laser (*list which type) Chemical peels (*list which type) Body contouring/fat reduction (*list which type)Extra Information*Please list your full AM skincare regimen.*Please list your full PM skincare regimen.*Name of your primary physician.*Phone number of your primary physician.*Please list any medications, prescriptions or supplements you are currently taking.*Please list down all your known allergies to medications.*Are you pregnant, planning on becoming pregnant or breast feeding?*Please provide current pharmacy address, phone number and fax number.**Financial/Insurance InformationDr. Kline does not participate with any health insurance. I understand that I am responsible for all charges incurred and that payment is due at the time services are rendered. We require a copy of your insurance card for laboratory purposes only.I request that payment of authorized Medicare benefits be made either to me or on my behalf to Mitchell Kline, M.D. for services furnished to me by the provider. I authorize any holder of medical information about me to release to CMS and its agents any information needed to be determine these benefits payable for related services.Carrier NameID #Group #Employer Sponsored?YesNoGovernment Sponsored?NoYesRelationship To Insured NameInsurance Billing Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country KINDLY GIVE 24HR HOURS NOTICE TO CANCEL APPOINTMENTS. A FEE OF $100.00 WILL BE BILLED TO YOU FOR LESS THAN 24HOUR HOURS NOTICE AS WELL AS FAILURE TO KEEP SCHEDULED APPOINTMENTSPatient Request for Email CommunicationsCommunications over the Internet and/or using the email system are not encrypted and may not be secure. There is no assurance of confidentiality when communicated via email. To request that this provider communicate with you via email you must complete this form.Please be advised that:This request applies only to the healthcare provider that you indicate below. If you would like to request to communicate via email with another health care provider or program, you must complete a separate request for that office.DR. MITCHELL A. KLINE will not communicate health information that is specially protected under state and federal law (e.g., HIV/Aids, substance abuse, mental health information) via email.Your request will not be effective until you receive and respond appropriately to a test email message.By signing this I agree to receive the following types of emails. Please check all that apply. I certify the email address provided on this request is accurate, and that I accept full responsibility for messages sent to or from this address. I have received a copy of the IMPORTANT INFORMATION ABOUT PATIENT EMAIL form, and I have read and understand it. I understand and acknowledge that communications over the Internet and/or using the email system are not encrypted and may not be secure: that there is no assurance of confidentiality of information when communicated this way. I understand that all communications in which I engage may be forwarded to other providers for purposes of providing treatment to me. I agree to hold DR. MITCHELL A. KLINE and individuals associated with him harmless from any and all claims and liabilities arising from or elated to this request to communicate via email. Pre and post care instructions related to in-office treatments. Appointment reminders and related follow up communications. New service information, skincare and practice specials relevant to Kline Dermatology.Receipt of Notice of Privacy Practices Written Acknowledgement FormAre you the patient, parent or legal guardian of the patient?*I am a patient of MITCHELL A. KLINE M.D., P.C. and have reviewed MITCHELL A. KLINE M.D., P.C.'s Notice of Privacy Practices. A copy of the notice is available upon request.I am a parent or legal guardian of the patient. I hereby acknowledge receipt of MITCHELL A. KLINE M.D., P.C Notice of Privacy Practices with respect to the patient.Name of Parent/Legal Guardian*Relationship to Patient*ParentLegal GuardianSignature*For desktop, move your cursor over the signature box to sign your name. For iPads or mobile phones, use your finger to sign. This iframe contains the logic required to handle Ajax powered Gravity Forms.