New Patient Packet Form

Please correct the errors described below.

Please fill out the general information/insurance information section and the medical information section completely so that we may efficiently and effectively treat your condition. Thank you -Advanced Foot and Ankle Center

***Please Upload Images of the Front & Back of Your Insurance Card***

To do this, please take a picture of your cards, front and back with your smart phone, then click on 'add file below to upload the picture. (Go into photo library, and choose the pictures, then upload)

    Please upload a file

    Add Additional Insurance

    I request payment of authorized Medicare benefits (and all insurances) to be made on my behalf to this office for services furnished to me. I authorize any holder of medical information about this patient to be released to Health Care Financing Administration or any insurance company or agents to help determine benefits payable for services rendered. I understand and agree that I will be responsible for the payment of services rendered to the above patient

    I also understand with today’s managed care systems of insurance, should my insurance require a referral, I realize that I must bring it in before my treatment and that it is my responsibility to request additional referrals from my Primary Care Physician after I have used up the original referrals or they become expired.

    Additionally, should this office find a need to refer me for tests, or any treatment to another facility, I need to call my insurance company and inquire if they participate and if I need referrals or precepts. I acknowledge that I was provided with a copy of the Notice of Privacy Practices and I have read (or had the opportunity to read if I so chose)and understood the Notice.

    I also understand that if I do not follow the rules of my insurance company, then I will be responsible for my charges. I have provided the office my email address and give permission the office to contact me via email.”

    I authorize this office to request medical records from any of my physicians as well as to release any of my medical records to my physicians.

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

    Is the patient being seen covered under a parent’s insurance?

    Please Fill out Completely

    Medications

    Click here to add additional medications

    Allergies

    Pharmacy Name / Location

    Past Medical History

    Surgical History

    Social History

    Family History

    Family History

    Review Of Systems

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

    History of present Illness:

    (Please fill out completely WITH REGARDS TO YOUR MAIN PROBLEM so we can best serve you)

    Chief Concern:

    Nature:

    Injury:

    Intensity:

    Location:

    Duration:

    Onset:

    Course:

    Aggravating Factors:

    Treatment:

    SECONDARY PROBLEM / CONCERN

    (Please fill out completely WITH REGARDS TO YOUR SECONDARY PROBLEM so we can best serve you)

    Secondary Concern:

    Nature: Please describe your condition (USE MORE THAN ONE IF NEEDED TO DESCRIBE)

    Nature:

    Injury:

    Intensity:

    Location:

    Duration:

    Onset:

    Course:

    Aggravating Factors:

    Treatment:

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

    Your information will be encrypted.

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