Topanga Medical — Patient Intake

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Patient Information

Legal Name (First)*

Middle Initial

Legal Name (Last)*

Prefer to be called

Date of Birth*

Age

Sex

Mailing Address (Street)

City

State

Zip

Home Phone

OK to leave message (Home Phone)

YesNo

Cell Phone

OK to leave message (Cell Phone)

YesNo

Occupation

Work Phone

Ext

OK to leave message (Work Phone)

YesNo

Email Address

Primary Language✓ From EHR

EnglishSpanishSomaliOther

Primary Language — Other

Race — Other

Ethnicity

HispanicLatinoNot Hispanic or LatinoPrefer not to Say

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Emergency Contact

Relationship

Phone #

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Primary Care Provider

Primary Care Physician and Clinic Name

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Responsible Party (if different from patient)

Name (First)

Name (Middle Initial)

Name (Last)

Date of Birth

Relationship to Patient

Address (Street, City, State, Zip)

Home Phone

Cell Phone

Work Phone

Ext

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Referral

How did you hear about Tareen Dermatology

Physician and Clinic Name

Family Member

Other

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Medical History

Have you had or currently have any of the following medical conditions:

Condition

Yes/No

Other medical condition

Are you currently pregnant?

YesNo

Planning Pregnancy

YesNo

Breast Feeding

YesNo

Have you had any surgeries? (Including joint replacement and heart valve surgeries)

No entries yet.

Medications: (including over-the-counter)

No entries yet.

Drug Allergies

No entries yet.

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Skin History

Do you have or have had any of the following skin conditions?

Skin Condition

Yes/No

Other skin condition

Do you have a family history of melanoma or other skin cancers?

YesNoUnknown

If yes, which relative? What type of skin cancer?

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Social History

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Pharmacy

Pharmacy Name

City/State

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Federally Required Questions

Please answer the following questions to the best of your ability. Please note that the United States Federal Government REQUIRES us to ask these questions.

I confirm that the information on this form is accurate and authorize Rempli to share it with my healthcare provider. I understand my EHR data was accessed using my patient portal login and may be stored by Rempli to pre-fill future forms.