New Patient Packet Form

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)

Click -add file- below to upload insurance card

Add file

Please upload a file

First Name

Last Name

Birthdate

SS #

Street Address 1

Street Address 2

City

State

Zip Code

Home Phone

Work Phone

Cell Phone

Family Doctor

None

If yes, who is your treating diabetic Doctor

Who referred you to our office

Emergency Contact

Phone

Spouse Name

Retired Employees - Place of Employment

Please check if you have one of the following health spending cards

H.S.A

H.R.A

FLEX CARD

NONE

If other, please specify Insurance

Policy Holder Name

Member ID Number

Policy Holder Date of Birth

Social Security (Required for billing)

Policy Holder Occupation

Employer

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.

Signature

Date

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

(Must click one)(If yes fill out the corresponding form as it appears)

Father's insurance Mother's insurance Not under a parent's insurance

Father's Name

Father's Date of Birth

Father's Social Security Number

Father's Occupation

Employer

Father's Work Phone

MUST CLICK ON ONE BELOW WITH REGARDS TO FATHER

Full-Time

Part-Time

Not Employed

Full-Time Student

Part-Time Student

Self-Employed

Military Service

Retired

Mother's Name

Mother's Date of Birth

Mother's Social Security

Mother's Occupation

Employer

Mothers work phone

MUST CLICK ON ONE BELOW WITH REGARDS TO MOTHER

Full-Time

Part-Time

Not-Employed

Full-Time Student

Part-Time Student

Self Employed

Military Services

Retired

Please Fill out Completely

Medications

Check If "NONE"

Click here to add additional medications

Allergies

Type of reaction to Aspirin

Type of reaction to Sulfa Drugs

Type of reaction to Penicillin

Type of reaction to Codeine

Type of reaction to Cephalosporin

Type of reaction to Tape

Type of reaction to Erythromycin

Type of reaction to Cortisone

Type of reaction to Tylenol

Type of reaction to Iodine

Type of reaction to Ibuprofen

Type of reaction to Tetracycline

Type of reaction to Novocaine

Type of reaction to Latex

List other allergies and reactions

Pharmacy Name / Location

If other, please specify

Past Medical History

If Cancer, What Type?

If other past medical history, please specify and list

Surgical History

If other, Please specify

Social History

Alcohol Use

Alcohol use (Social drinker)

Alcohol use (Heavy drinker)

Alcohol (Recovering alcoholic)

Alcohol use (non-drinker)

Smoking

Smoking (former smoker)

Smoking (Heavy smoker)

Smoking (Light smoker)

Smoking (Never smoked)

Family History

Check all that applies or select none

Diabetes

Gout

Stroke

Hypertension

None

Diabetes

Mom

Dad

Gout

Mom

Dad

Stroke

Mom

Dad

Hypertension

Mom

Dad

Check all that applies or select none

Cancer

Heart disease

Depression

Rheumatoid arthritis

None

Cancer

Mom

Dad

Heart disease

Mom

Dad

Depression

Mom

Dad

Rheumatoid arthritis

Mom

Dad

Check all that applies or select none

Osteoarthritis

Sickle cell anemia

Other

None

Osteoarthritis

Mom

Dad

Sickle cell anemia

Mom

Dad

If Other, Specify

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.

Signature

Date

History of present Illness:

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

Chief Concern:

What is your main concern for coming to the office? Please Describe in one brief statement. Please keep your response below 120 characters

Nature:

Describe other

Injury:

Was there an injury?

Yes No

If other, please list

If other, please describe

Intensity:

Location:

Please be specific as to location of your problem, ex: top of right foot, outside of right ankle, left big toe, bottom of left heel, etc.

Duration:

If other please specify

Onset:

If other please specify

Course:

If other please specify

Aggravating Factors:

If other, please describe

Treatment:

If other, please describe

Do you have a Secondary Concern? (iif yes please fill out all of the fields that appear below after clicking yes)

Yes No

SECONDARY PROBLEM / CONCERN

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

Secondary Concern:

Any other concern for coming to the office? Please describe

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

Nature:

Describe other

Injury:

Was there an injury?

Yes No

If other, please list

If other, please describe

Intensity:

Location:

Please be specific as to location of your problem, ex: top of right foot, outside of right ankle, left big toe, bottom of left heel, etc.

Duration:

If other, Please specify

Onset:

If other, Please specify

Course:

If other, Please specify

Aggravating Factors:

Condition is aggravated by? (choose more than one if needed)

Increased activity

Walking

Running

Going down stairs

Going upstairs

Wearing shoes

Going barefoot

Periods of rest and hurts when getting back up on feet

Other

If other, please describe

Treatment:

If other, please describe

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.

Patient's Name / Signature

Date of Birth

Today's Date

Your information will be encrypted.