Allergies & Contact Information

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SHELBY DERMATOLOGY, PC | ROBERT L. HENDERSON JR. MD | GREGORY P. BOURGEOIS MD ALLERGIES

Are you allergic to any local anesthetics? Lidocaine / Xylocaine / Novacaine __ Y

__ N

If yes, which one(s)___________________________________________________

Other known DRUG Allergies___________________ ____________________ ____________________ ___________________ ____________________ ____________________ ___________________ ____________________ ____________________ Do you smoke? Y/N

How much? _________________

Race/Ethnicity ______________ CONTACT INFORMATION

In the event we need to contact you regarding an appointment confirmation, lab/biopsy result, or to discuss any relevant information related to your care: May we contact you at work? __ Y

__ N Work #: (____)_____-________ (Please initial)______

May we leave a message on your answering machine? __ Y May we discuss with family members/friends? __ Y

__ N (Please initial) _______

__ N _______

if so, please list; (Please initial) _______

FIRST NAME

LAST NAME

RELATIONSHIP

PHONE NUMBER

FIRST NAME

LAST NAME

RELATIONSHIP

PHONE NUMBER

FIRST NAME

LAST NAME

RELATIONSHIP

PHONE NUMBER

PHARMACY Name:

_____________________________________________ Street: ____________________________________________________

PHONE

#: (____)_____-________