Section 1: Patient Information Form

Foot & Ankle Center of Lake City

PATIENT INFORMATION

Last Name:

First Name:

MI:

Generation

Gender

Male Female

Email:

Add Billing Address (If Different from Home Address)

Home Phone:

Work Phone:

Cell:

Employer:

Occupation:

Birth Date:

Age:

SS #:

Marital Status:

Single Married Divorced Widowed Partnered

Spouse/Partner

Name:

Phone:

Emergency Contact:

Relationship:

Phone:

Primary Language:

Ethnicity

Hispanic or Latino Non Hispanic or Latino Decline

Race:

American Indian or Alaska Native Asian Black or African American Native Hawaiian Other Pacific Islander White Decline

Contact Message: (Ok to leave voicemail or email message with:)

Patient Spouse Anyone answering the phone

INSURANCE INFORMATION

Is your insurance through your employer?

Yes No

Primary Insurance

Add Secondary Insurance

Primary Care Physician

Name:

Address:

City:

State:

Zip Code:

Phone:

Fax:

Specialty Physician

Name:

Address:

City:

State:

Zip Code:

Phone:

Fax:

How did you hear about our practice?

Internet Search Insurance Family Friend Other

If Family, Please Specify:

If Friend, Please Specify:

If Other, Please Specify:

*We will periodically send medical, educational, and promotion via email.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Patient/Parent Signature:

Date

Your information will be encrypted.