New Patient Packet

PATIENT INFORMATION

Date:

Last Name:

First:

MI:

Address:

City/State:

ZIP:

Email Address:

Home #:

Work #:

Cell #:

Date of Birth:

Age:

Sex:

Marital Status:

Driver License #:

SSN:

Patient's Employer:

Position:

Select one:

Full Time Part Time Student Retired

Referred By:

Personal Physician:

Spouse's Name:

Date of Birth:

Spouse's Employer:

Work Phone:

PERSON RESPONSIBLE FOR BILL

Name:

Relationship to Patient:

Address:

City/State:

ZIP:

Home #:

Work #:

Cell #:

NEAREST RELATIVE TO NOTIFY IN AN EMERGENCY NOT LIVING IN YOUR HOME

Name:

Relationship to Patient:

Home #:

Work #:

Cell #:

Primary Insurance:

Name of Insurance:

Insured's Name:

Insured Date of Birth:

Insured's SSN:

Group #:

ID #:

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I hereby assign, transfer, and set over to Lauren Gibson, DPM all of my rights, title, and interest to my medical reimbursement benefits under my insurance policy. I authorize the release of any medical information needed to determine these benefits. This authorization shall remain valid until written notice is given by me revoking said authorization. I understand payment is expected at the time services are rendered. I understand that I am financially responsible for charges (co-pays, deductibles, co-insurances) whether or not they are covered by my insurance. I also understand I am financially responsible for charges incurred if insurance does not pay in a timely manner. I have read, understand, and agree to the above financial policy.

Signature:

Date:

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

OFFICE POLICIES

1. Scheduled Appointments

We understand that delays can happen however we keep a very full busy schedule, so if a patient is 15 minutes past their scheduled appointment time, we may have to reschedule that appointment. The appointment will be rescheduled for the next availability or depending on our office schedule for the day, you may wait in office to be seen.

2. No Show Policy for Doctors Appointment

We understand that there are times when you must miss an appointment due to emergencies or obligations for work or family. However, when you do not call to cancel an appointment, you may be preventing another patient from getting much needed treatment.

A fee could be assessed of $20 and this fee will not be covered by insurance and will need to be paid prior to another appointment being scheduled.

3. No Show Policy for Surgical Procedures

Due to the large block of time needed for surgical procedures in office, no shows may cause problems and added expenses for the office.

If you no show for an in office surgical procedure there will be a $30 fee. This fee will not be covered by insurance and will need to be paid prior to another appointment being scheduled.

4. Account Balances

We will require that patients with self-pay balances must pay their account balances to zero (0) prior to receiving further services by our practice.

Patients with account balances over $100 must make payment arrangements prior to appointments being made.

Patients who have questions about their bills or who would like to discuss a payment plan option may call and ask to speak to a business office representative with whom they can review their account and concerns.

Signature Patient/Guardian:

Date:

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

Patient Account #:

(Office Use only)

MEDICAL INFORMATION RELEASE FORM

(HIPAA RELEASE FORM)

Name:

Date of Birth:

RELEASE OF INFORMATION

I authorize the release of information including the diagnosis, records, examination rendered to me along with claims information. This information may be released to:

Name:

Relationship:

Add new row for another family member

Dr.:

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Information is not to be released to anyone.

This Release of information will remain in effect until terminated by me in writing.

Signature:

Date:

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

MEDICAL INFORMATION

THIS INFORMATION IS IMPORTANT FOR OUR RECORDS AND YOUR HEALTH

DESCRIBE YOUR FOOT PROBLEM:

HOW DID THIS PROBLEM START?

Sudden Gradual

WHEN DO YOU HAVE THIS TROUBLE?

Everyday Off and On

HOW LONG HAS IT BEEN BOTHERING YOU?
EXAMPLE: 2 DAYS, 4 WEEKS, 6 MONTHS, 2 YEARS

Days:

Weeks:

Months:

Years:

WHAT TYPE OF PAIN ARE YOU EXPERIENCING?

Achy

Throbbing

Sharp

Burning

Numbness

Shocking

Dull

Electric

SEVERITY OF PAIN?

Mild Moderate Severe

DOES THIS PROBLEM AFFECT YOUR FUNCTION IN ANY WAY? (EXAMPLES: LIMPING, CAN'T WEAR SHOES, WAKES YOU UP AT NIGHT)

WHAT HAVE YOU DONE TO TREAT THIS PROBLEM?

SHOE SIZE:

CURRENT WEIGHT:

HEIGHT:

EMPLOYMENT:

Sit down job

Stand at job

Stand & walk at job

Retired

REVIEWED BY:

Check all that apply (provide Dr. Name treating conditions in capital letters)

AVERAGE BLOOD SUGAR:

***VASCULAR DOCTOR:

DRUG ALLERGIES AND EFFECTS:

Are you sensitive to:

Tape:

Yes No

Betadine (Iodine):

Yes No

Latex:

Yes No

List Medications:

List any surgeries and dates:

List any hospitalizations other than surgeries:

List any complications with anesthesia or reactions:

SOCIAL HISTORY:

Do you smoke?

Yes No

If you smoke, # packs per day?

Previously smoked?

Yes No

If previously smoked, # years?

When Quit?

Do you drink alcohol/beer?

Yes No

If you drink alcohol/beer, select:

Light use 1-2 per week

Moderate use 1-2 per day

Heavy more than 2 a day

Any recreation drug or IV usage?

If other, specify:

Mother:

If living, age:

If deceased, cause of death:

Father:

If living, age:

If deceased, cause of death:

Brother:

If living, age:

If deceased, cause of death:

Sister:

If living, age:

If deceased, cause of death:

CHECK ALL THAT APPLY:

REVIEW OF SYSTEMS:

HEAD:

Chronic headaches

Concussions

Dizziness

Loss of consciousness

EYES:

Glasses

Diplopia

Blurred vision

Blindness

Glaucoma

Cataracts

EARS:

Decreased or loss of hearing

Tinnitus

Chronic earaches

Drainage or infections

NOSE:

Chronic drainage

Blockage

Sinusitis

THROAT:

Chronic tonsillitis

Laryngitis

Dysphagia

Loss of speech

Thyroid disorders

RESPIRATORY:

Asthma

Bronchitis

Pleurisy

Emphysema

Pneuomonia

Trauma

GU:

Chronic kidney or bladder infections

Stones

Urinating frequently

Urinating rarely

Blood in urine

Pain with urination

SKIN:

Recent hair loss to legs

Color change

Psoriasis

Blisters/rash

Change in texture thin/shiny

OTHER:

Marfans Syndrome

CRPS/RSD

Ehlers-Danlos Syndrome

If other, specify:

Name of Pharmacy or Drug Store:

Phone#:

HOW DID YOU HEAR ABOUT US?

Your information will be encrypted.

New Patient Packet

PATIENT INFORMATION

PERSON RESPONSIBLE FOR BILL

NEAREST RELATIVE TO NOTIFY IN AN EMERGENCY NOT LIVING IN YOUR HOME

OFFICE POLICIES

1. Scheduled Appointments

2. No Show Policy for Doctors Appointment

3. No Show Policy for Surgical Procedures

4. Account Balances

MEDICAL INFORMATION RELEASE FORM

(HIPAA RELEASE FORM)

RELEASE OF INFORMATION

MEDICAL INFORMATION

Check all that apply (provide Dr. Name treating conditions in capital letters)

SOCIAL HISTORY:

CHECK ALL THAT APPLY:

REVIEW OF SYSTEMS:

ACADIA FOOT CARE