Welcome to Dawes Fretzin Dermatology Group

We are honored that you have chosen us for your skin care needs, and we promise to provide you with the best care available. This page introduces you to some of our office policies and likely answers many questions you may have. Kenneth Dawes, MD, established our practice in 1995; he partnered with Scott Fretzin, MD, forming Dawes Fretzin Dermatology Group in 1997. In 2007, we welcomed Christy Nebesio, MD and Priya Young, MD. We were thrilled when Mary Spolyar, MD joined in 2009 and Ann-Marie Hyatt, MD in August 2012. In 2014 Nicholas Countryman, MD, a Mohs surgeon entered our practice to further expand the services we provide our patients. Later that year we happily added Kathryn Shrift, MD, to our staff as well.

SERVICES Dawes Fretzin Dermatology proudly offers a variety of dermatologic treatments, including medical and surgical management of diseases of the skin, hair and nails, as well as cosmetic services to enhance the appearance of your skin. Our cosmetic services include, but are not limited to:

Laser treatment for removal of hair, tattoos, pigmented skin lesions and fine blood vessels on the face

Botox Cosmetic©, Restylane, Radiesse and Juvederm for facial wrinkles

Sclerotherapy treatment of spider veins of the legs

Vibradermabrasion, Chemical Peels, Facials, Dermaplaning and Waxing

Physician skin care products and Mineral Makeup Same day appointments for our Esthetician may be available. Please inquire at the front desk.

APPOINTMENTS We strive to give all patients the earliest available appointment. If you have a very urgent problem, your primary care physician’s office is welcome to call us with the details. We request 24 hours notice for cancellations, as this will enable us to fill the appointment time; there is a $25 fee for missed appointments without appropriate notice. There is also a $75 missed appointment fee for laser/cosmetic/esthetics appointments. We reserve the right not to reschedule you if you repeatedly miss appointments.

WHAT TO BRING

A complete list of the medications (prescription and non-prescription) you are currently taking

Your most recent insurance card(s)

A photo ID

A referral from your primary care physician, if necessary/required by your insurance plan

PAYMENT FOR SERVICES By contract, we are required to collect copays at the time of service. We accept cash, check and Visa/MasterCard/Discover. We will bill your insurance company and we do accept assignment from them. Any remaining balance will be billed to you. If you do not have insurance, or do not have your card with you for your visit, full payment will be necessary at the time of service. Accounts referred to an attorney for collection will incur an additional charge.

Please visit us at www.dawesfretzin.com

PRESCRIPTION REFILLS Please call our office during regular business hours to request prescription refills. We try to accommodate these requests on the same day, though it is not always possible. Return calls will only occur if there is a problem or question regarding your request; you should call your pharmacy to see if the refill has been called in. Yearly visits are necessary to maintain a status as an active patient and to qualify for prescription refills.

TELEPHONE CALLS We understand how frustrating it is to be stuck in a phone messaging system when you call an office. Below you will find a few extensions that you may dial as soon as the message system is engaged. If you leave a message on the scheduling line, you will receive a call back within 24 hours. Our phones are on from 7:30 to 4:30. 2 Scheduling/Referrals/Front Desk

3 Nursing (prescription refills, medical questions) 5 then 1 Billing Department If you have an urgent medical need outside of office hours, dialing our office number will tell you how to reach the doctor on call. Routine prescription refills and lab/pathology results are not available after business hours.

OUR OFFICE LOCATIONS

Indianapolis (Castleton) 8103 Clearvista Parkway Suite 220 Indianapolis, IN 46256 (317) 516-5000 Kokomo 3611 South Reed Rd Suite 105 Kokomo, IN 46902 (317) 516-5000 Mohs North 8801 N. Meridian St Suite 207 Indianapolis, IN 46260 (317) 516-5000

Anderson 1601 Medical Arts Blvd Suite 303 Anderson, IN 46011 (317) 516-5000 Indianapolis (East) 10122 East 10th St Suite 230 Indianapolis, IN 46229 (317) 516-5000

Patient Name_________________________________ Account# (office use) _______________

I understand and agree that for services rendered by Dawes/Fretzin Dermatology Group, LLC (the ”Group”), full payment is due at the time of service for any and all costs that are not covered by an insurance carrier, government payer (including Medicare and Medicaid), or other third party payer (together, referred to as a ”Payer”). This includes amounts for services that are not covered by insurance, co-pays, coinsurance, deductibles, and past due balances unless previous arrangements have been made with the Group’s billing department. In the event a Payer denies all or part of a claim filed by the Group, I agree to pay to the Group all charges and account balances that are not paid in full and understand that payment will be due by the due date contained in any statement I receive from the Group. A $150.00 fee will be assessed for missed Mohs surgery appointments or Eyelash extension appointments without 24 hour notice. A $75.00 fee will be assessed for missed surgical, cosmetic, esthetics and Blu Light appointments without 24 hour notice. A $25.00 fee will be assessed for all other missed appointments without 24 hour notice and for returned checks.

For any past due amounts, the Group shall be entitled to payment from me of interest at the rate of 1.5% per month (18% per annum), and I agree that I shall be responsible for all costs and expenses incurred by the Group in efforts to collect past due amounts from me, including interest charges, court costs, reasonable attorneys’ fees and other collection costs and expenses. If amounts due from me are turned over to a third party for collection, I agree to be responsible for the collection fees and expenses. In the event a check is returned for insufficient funds, all charges incurred by the Group shall be my responsibility. Each party further agrees that the Marion County Circuit, Superior, or Small Claims Court shall be the proper court of jurisdiction and venue. Further, each party waives trial by jury.

I hereby authorize payment directly to the Physician of the Surgical and/or Medical Benefits, if any, otherwise payable to me for his/her services as described, realizing I am responsible to pay non-covered services. I also authorize the Physician to release any information acquired in the course of my treatment necessary to process insurance claims.

I (we) the undersigned parent, parents, or legal guardian of a minor do hereby authorize and consent to any medical exam or treatment rendered under the general or special supervision of a duly licensed physician, licensed under the provisions of the laws in the State of Indiana. It is understood that this authorization is given in advance of any specific diagnosis, treatment or medical care being required but is given to provide authority and power to render care, which the aforementioned physician in the exercise of his/her best judgment may deem advisable. It is understood that effort shall be made to contact the undersigned prior to rendering treatment to this patient, but that any of the above treatment will not be withheld if the undersigned cannot be reached.

I request and give consent to my physician to provide and perform such medical/surgical care, tests, procedures, drugs and other services and supplies as are considered necessary or beneficial by my physician for my health, and well-being. I acknowledge that no representations, warranties or guarantees as to the results or cures have been made to me or relied upon by me.

I give consent and authorization for the Medical or Billing Staff of my Physician’s office to leave Protected Health Information about me or for me on my answering machine or voicemail via the telephone number I have listed. I understand I may revoke this privilege at any time by submitting my request in writing to this office.

I acknowledge a receipt of a copy of Notice of Privacy Practices

Date ___________________________

Patient or Parent/Guardian Signature: ___________________________________________________

*If Patient is a minor please complete the following

Parent/Guardian Printed Name: ________________________________________________________

Parent/Guardian Date of Birth___________________

Relationship to Patient_________________________________________________________________

*I hereby give my consent for the above named patient to be seen without a Parent/Guardian present.

___________please initial

Notice to Patients

Although we are affiliated with Community Hospital Network we do not use, and will not be

transitioning to, the EPIC EMR system they use. You will be required to fill out demographic and medical

history documentation for Dawes Fretzin Dermatology. We apologize if this causes any inconvenience.

PATIENT REGISTRATION FORM

PATIENT INFORMATION First Name: MI: Last Name:

Mr. Mrs. Ms.

Address: City/State/Zip:

Nickname: Date of Birth: Sex:

Male Female

Social Security Number:

Home Phone: Work Phone: Cell Phone: E-Mail:

Marital Status:

Single Married Divorced Widowed

Would you like to receive medical/cosmetic

newsletter by email?

Yes No Family Doctor: Family Doctor Phone No.

Referring Doctor if Different: Referring Doctor Phone No.

INSURANCE HOLDER First Name: MI: Last Name:

(If other than patient) Mr. Mrs. Ms. Address: City/State/Zip:

Home Phone: Work Phone: Ext:

Date of Birth: Sex:

Male Female

Social Security Number: Relationship to Patient:

GUARANTOR First Name: MI: Last Name:

(If other than patient) Mr. Mrs. Ms. Address: City/State/Zip:

Home Phone: Work Phone: Ext:

Date of Birth: Sex:

Male Female

Social Security Number: Relationship to Patient:

OTHER INFORMATION

Pharmacy Name & Location: Phone Number:

Emergency Contact Name & Relationship: Phone Number:

Race

Preferred Language

Ethnicity

Preferred Method of Communication: EMAIL HOME PHONE MOBILE PHONE

Name: _____________________________________ DOB: _____________________ Height: ____________ Weight: _______

Primary Care Physician/Pharmacy

Who is your Primary Care Physician (PCP)? _________________________________________ Did a physician specifically refer you to our office for this problem? _________________________________________ If yes, what is the name of the referring physician? _________________________________________ Pharmacy Name/Location/Phone #: _____________________ _________________________________________

Please list the reason(s) for your dermatology visit:

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

Preferred Method of Contact (pleased circle):

Cell Phone Home Phone Work Phone Email

Past Medical History (Please Circle YES or NO)

History of non-melanoma skin cancer

(basal cell, squamous cell)

History of Melanoma

CARDIOVASCULAR High Blood Pressure

Coronary Artery Disease (CHF, Heart Attack)

Arrhythmia (Irregular Rhythm)

Valve Disease/

PULMONARY Asthma/Emphysema

Tuberculosis

RENAL/KIDNEY Renal/Kidney Insufficiency

LIVER/GASTROINTESTINAL Hepatitis

Cirrhosis

Ulcers

Ulcerative Colitis/Crohn’s Disease

EYE Cataracts

Glaucoma

NEUROLOGIC/PSYCHIATRIC

Seizures/Epilepsy

Stroke

Migraines

Depression/Anxiety/Other

ENDOCRINE Diabetes

Thyroid Abnormality

High Cholesterol

GENERAL Do you require antibiotics before procedures

Due to valve or joint replacement?

Osteoporosis

Arthritis (Osteo or Rheumatoid)

AIDS/HIV +

Sun Sensitivity

History of any cancer (other than skin)

Any additional Medical History

YES

YES

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Explain:______________________________________________________

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SMOKING HISTORY

Current tobacco smoker

Current smokeless tobacco use

YES

YES

NO

NO

If so, when started? ______________________________________

If so, when started? ______________________________________

Name: _____________________________________ DOB: _____________________ Height: ____________ Weight: _______

Past Surgeries/Date: _______________________

If you have no past surgeries, check here:

PREVIOUS SURGERIES: DATE OF SURGERY: 1. _____________________________________________________ ____________________________________________________________

2. _____________________________________________________ ____________________________________________________________

3. _____________________________________________________ ____________________________________________________________

4. _____________________________________________________ ____________________________________________________________

5. _____________________________________________________ ____________________________________________________________

6. _____________________________________________________ ____________________________________________________________

7. _____________________________________________________ ____________________________________________________________

8. _____________________________________________________ ____________________________________________________________

9. _____________________________________________________ ____________________________________________________________

10. _____________________________________________________ ____________________________________________________________

SIGNIFICANT FAMILY HISTORY (PLEASE CIRCLE): Adopted (unknown)

Skin Cancer (non-melanoma)

Melanoma

- If yes, any family history of Pancreatic Cancer

Skin Disease

Psoriasis

Autoimmune Disorder (Lupus, RA, Thyroid)

Eczema

Cancer, other than skin

(Please specify)

YES

YES

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NO

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NO

NO

Explain:______________________________________________________

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Explain:______________________________________________________

Explain:______________________________________________________

List your current medications (prescription and over the counter):

If you take NO medications, check here:

DRUG DOSAGE PRESCRIBED BY BAD REACTION? 1. ____________________________

2. ____________________________

3. ____________________________

4. ____________________________

5. ____________________________

6. ____________________________

7. ____________________________

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List any allergies to medication and non-drug allergens.

If you have NO allergies, check here:

ALLERGIC TO: TYPE OF REACTION: 1. __________________________________________________ __________________________________________________________

2. __________________________________________________ __________________________________________________________

3. __________________________________________________ __________________________________________________________

4. __________________________________________________ __________________________________________________________

5. __________________________________________________ __________________________________________________________

SOCIAL HISTORY

Do you live alone?

Do you drink alcohol?

Are you pregnant or planning on becoming pregnant?

Pregnancy prevention method?

YES

YES

YES

YES

NO

NO

NO

NO

If so, how much/often? _________________________________________

If so, please explain: _________________________________________

EMPLOYMENT HISTORY

Do you work outside the home?

Occupation:

Place of Employment:

YES NO

_____________________________________________________

_____________________________________________________

Dawes Fretzin Dermatology Group

317-621-7790, ext. 111

1/1/2017 1/1/2017