Medical Information

Steve Clark, DPM

Office Use

Brian O’Carroll, DPM

Office Use

Byron Collier, DPM

Office Use

911 Oak Park Blvd, Ste 106, Pismo Beach, CA 93449 t: (805) 481-9100 f: (805) 481-9199

1525 E Main St, Ste B, Santa Maria, CA 93454 t: (805) 354-7990 f: (805) 354-7009

Patient First Name

Last Name

Date of Birth

Reason for Visit:

How long have you had this issue?

Have you seen another Dr. for this problem?

Yes No

If Yes, Doctor's Name

When?

Primary Care Physician

Date Last Seen

Did someone refer you to us?

Yes No

If yes, Who?

Primary Care Physician Another Dr. Hospital / ER Another Patient

Name of Doctor or Patient Refereed by (If Applicable)

Other Physicians you regularly see

Preferred Pharmacy

Preferred Lab

Preferred Imaging Center

Medication Allergies

Height

Weight

Past Surgeries /Approximate Date

Past Surgery

Approximate Date

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Tobacco Use

Never Former (Specify # of Years below) Current (Specify amount per day/wk/mo below)

# of Years

Amount per day/wk/mo

Alcohol Use

None Occasional Moderate Heavy

Please Specify Other

Release of Information: I hereby authorize the above provider and his staff/business partners to 1) release to my insurance company and its agents, all information needed to determine benefits payable for related services, 2) process insurance claims generated in the course of examination or treatment; and 3) allow a photocopy of my signature to be used to process insurance claims.

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Patient/Guardian Signature

Date

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