Dermatology of the Berkshires, P.C
Victoria R. Cavalli, M.D.
40 Main Street ∙ North Adams, Massachusetts ∙ 01247 ∙ (413) 663-6769
Today’s Date: _____________________
Name: _______________________________________________________________________
LAST
FIRST
MIDDLE INITIAL
Address: _____________________________________________________________________
City: __________________________________State: ________________Zip: _____________
SSN: _________________________________ DOB: ________________ Age: ____________
Home Phone: ___________________________Work Phone: ___________________________
Cell Phone: ____________________________ Occupation: ____________________________
Mailing Address (if different): ____________________________________________________
City: __________________________________State: ________________Zip: _____________
Primary Care Physician: ________________________ Phone: __________________________
Address: _____________________________________________________________________
City: __________________________________State: ________________Zip: _____________
Pharmacy: __________________________________ Phone: ___________________________
Address: _____________________________________________________________________
City: __________________________________State: ________________Zip: _____________
May we contact you regarding upcoming specials and events by e-mail? Yes or No
E-mail address: ________________________________________________________________
DERMATOLOGY OF THE BERKSHIRES, P.C.
VICTORIA R. CAVALLI, M.D.
HIPAA PRIVACY NOTICE
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE
DISCLOSED. PLEASE REVIEW IT CAREFULLY.
Dermatology of the Berkshires, P.C. will use your medical information for the following:
1. TREATMENT: Including providing your medical records to
consulting clinicians and insurance companies.
2. PAYMENT: Dermatology of the Berkshires, P.C. will file necessary
claims to insurance companies in your name to obtain payment. They
may request part or all of your medical record to pay the claim.
3. HEALTH CARE OPERATIONS: Any others involved in your
healthcare.
The entire HIPAA POLICY NOTICE of Dermatology of the Berkshires, P.C. is posted in the
waiting room for your perusal.
In conjunction with these privacy practices you will need to provide us with the following
information:
1. Name of person(s) Dermatology of the Berkshires, P.C. may speak to
regarding your health (i.e. spouse, child, etc. including phone number.)
____________________________________________________
____________________________________________________
2. May Dermatology of the Berkshires, P.C. leave a message regarding
your health or an upcoming appointment on your answering machine?
YES _____________
NO ____________
_______________________________
Signature of Patient or Legal Guardian
__________________
Relationship to Patient
_______________________________
Print Patient’s Name or Legal Guardian
__________________
Patient’s Date of Birth
Dermatology of the Berkshires, P.C.
Victoria R. Cavalli, M.D.
40 Main Street ∙ North Adams, MA 01247 ∙ (413)663-6769
INSURANCE/PAYMENT INFORMATION
Name: _________________________________________________ DOB: _____________________________
Thank you for choosing Dermatology of the Berkshires, P.C. for your health care needs. Along with providing
you with quality service, Dermatology of the Berkshires, P.C. would also like to assist you with your billing
needs. Please read the provisions below and mark the billing class that represents you:
_____ 1. Medicare only. Dermatology of the Berkshires, P.C. will file Medicare for you. Dermatology of the
Berkshires, P.C. accepts assignment; however, you will still be responsible for the 20% that Medicare
does not cover.
_____ 2. Medicare/Supplement. Dermatology of the Berkshires, P.C. will file both insurances. However, claims
denied, rejected or partially paid by your supplemental carrier will be your responsibility in 30 days.
_____ 3. HMO. Dermatology of the Berkshires, P.C. will file to your insurance carrier. It will be your
responsibility to obtain necessary authorization by your primary care physician. Visits not authorized
will be your responsibility. You will be responsible for your copayment.
_____ 4. PPO. Dermatology of the Berkshires, P.C. will file to your insurance carrier. You will be responsible
for any coinsurance, copayments and deductibles. Patients going out of their network will be responsible
for payment at a higher rate.
__X__ 5. Self-Pay. Payment is due at the time services are rendered unless prior arrangements have been made.
Dermatology of the Berkshires, P.C. will accept cash, checks, Visa and MasterCard.
Monthly statements will be sent to advise patients as to the status of their account.
I understand the billing procedures of Dermatology of the Berkshires, P.C. and agree to pay any balances that
are my responsibility. Balances unpaid will result in collection actions.
Signature: ____________________________________________________ Date: _______________________
Witness: __________________________________________________________________________________
PAYMENT POLICY: In order to establish optimal relations with our patients and avoid misunderstanding and confusion
regarding our payment policies, our staff is trained to consistently inform you of the financial payment policies of this office. Payment
is required for all services at the time they are rendered unless you are in a prepaid plan in which we participate. For those patients,
applicable copayments and deductibles will be collected. We accept payment in the form of cash, check or credit card. In the event of
hospitalization or major procedures, our office may file with the appropriate insurance. However, before such claims are filed,
coverage will be preverified and you will be asked to pay any unmet deductible, non-covered services and copayments. In the event
that your account must be turned over to collections, a $20.00 collection fee will be added to your account. Your signature below
signifies your understanding and willingness to comply with this policy.
Signature: _______________________________________________________________ Date: ______________________________
DERMATOLOGY OF THE BERKSHIRES, P.C.
VICTORIA R. CAVALLI, M.D.
40 Main Street ∙ North Adams, MA 01247 ∙ (413)663-6769
COSMETIC MEDICAL INFORMATION
NAME: ________________________________ DOB: ___________ AGE:______ DATE: ________________
Reason for visit: ____________________________________________________________________________
MEDICAL HISTORY:
Are you under the care of a physician at this time? □Yes □No
If yes, for what conditions? ____________________________________________________________________
Please check any conditions below that you have:
□ Cardiac problems (pacemaker of defibullator)
□ High Blood Pressure
□ Surgical Implants
□ Keloids/Scarring
□ Bleeding disorder/bruise easily
□ Impaired healing
□ Diseases stimulated by light (epilepsy/lupus)
□ Cancer
□ Diseases stimulated by heat (herepes simplex, rosacea) □ Arthritis
□ Skin disorders or lesions
□ Cold sores/fever blisters
□ Hormone imbalance (PCOS)
□ Diabetes
□ Thyroid disease
□ Hepatitis
□ HIV/AIDS
□ Vitiligo
Other medical conditions: _____________________________________________________________________
Do you smoke? □Yes □No
Do you drink alcohol? □Yes
If yes, how much? _________________________________________________
□No If yes, how many drinks/daily/weekly? ____________________________
SURGICAL HISTORY:
Please list all surgeries and approximate dates: ______________________________________________________
__________________________________________________________________________________________
IPL/LASER HISTORY:
Please list treatments, location and approximate dates: _______________________________________________
__________________________________________________________________________________________
LIPOSUCTION HISTORY:
Please list treatments, location, and approximate dates: _______________________________________________
__________________________________________________________________________________________
LEG VEIN HISTORY:
Please list any vein stripping, sclerotherapy, or laser vein treatments and approximate dates: _______________
__________________________________________________________________________________________
COSMETIC HISTORY:
Have you had any of the following injections or fillers? Please check all that apply.
□ Collagen □ Restylane/Perlane
□ Juvederm □ Botox
□ Dysport
Other: _____________________
Date of last treatment: _______________________
MEDICATIONS:
Please list any prescription drugs, dietary supplements, herbal remedies or other over-the-counter medications
that you take: ______________________________________________________________________________
__________________________________________________________________________________________
Have you ever had Accutane or gold therapy? □Yes □No
ALLERGIES:
Are you allergic to any medicines, foods or products? □Yes □No If yes, which ones: ____________________
__________________________________________________________________________________________
Have you ever had an allergic reaction to any of the following? Please check all that apply.
□ Latex
□ Lidocaine
□ Anesthesia
□ Topical anesthetics
FAMILY HISTORY:
Do you have family history of skin disorders (such as eczema, psoriasis, skin cancer, keloids/scarring),
autoimmune diseases, bleeding disorders, clotting disorders, varicose veins and/or excessive hair? □Yes □No
__________________________________________________________________________________________
SOCIAL HISTORY:
Occupation: ________________________________
Hobbies: __________________________________
SKIN TYPE:
Ancestry: _________________________________________________________________________________
Which of the following best describes your skin reactions when you are in the sun?
□ Always burns, never tans
□ Rarely burns, always tans
□ Always burns, sometimes tans
□ Brown skin
□ Sometimes burns, always tans
□ Black skin
Are you tan? □Yes □No
Please check: □ Sun tan
□ Tanning bed
□ Self tanner □ Spray tan
Do you plan to go on vacation in the near future? □Yes □No
Do you wear sunscreen? □ Never
□ Sometimes
□ Always
What SPF do you wear? ________________
How often do you apply sunscreen? ___________________
What skin care products do you use (cleanser, moisturizers, retinoids, or other anti-aging cosmeceuticals? ________
__________________________________________________________________________________________
Do you have any tattoos? □Yes □No If yes, please list the location(s): _______________________________
Do you have any permanent makeup? □Yes □No If yes, please list the location(s): _____________________
Do you have any beauty marks? □Yes □No If yes, please list the location(s): __________________________
Do you have problems with hypo or hyperpigmentation (lightening or darkening of the skin)? □Yes □No
How did you hear about this office:
□ Doctor ___________________________
□ Friend/Family _____________________
□ Website __________________________
□ Newspaper
□ Magazine
□ Phone book
Signature: ____________________________________________________________ Date: ________________