Patient Registration Form

Please correct the errors described below.

Family/PCP Physician:

Pharmacy:

Please check all methods we may utilize to speak with you or to leave you a detailed message:

TEXT / Email / Patient Portal:

*** Please sign separate designation for release of medical information form**

Emergency Contact: *****Please list name of someone NOT living in your household*****

Complete Foot and Ankle Specialists, Inc. does not honor advanced directives. We will call 911 to provide life support to any patient in distress.

After treatment, the patient will be turned over to their treating physician for continuing care and we will provide them with the name of your custodian of document you listed above.

INSURANCE INFORMATION:

*** Insurance Card(s) and photo ID must be given to front desk at time of service ***

Will this treatment be done as a result of?

I, the undersigned, certify that I (or my dependent) have coverage with my insurance as presented and assign directly to Complete Foot and Ankle Specialists, LLC all insurance benefits, payable to me for services rendered. I understand that I am responsible for payment of deductibles, co-payments, and/or non - covered services. I hereby authorize the doctor to release all information necessary to secure payment of benefits. I authorize the release of my medical information to my insurance carrier or requested physician to provide continuity of care. I authorize the use of this signature on all insurance submissions. I understand that it is my responsibility to inform Complete Foot and Ankle Specialist, LLC if there is a change in my health insurance information.

I hereby give permission to Complete Foot and Ankle Specialists, LLC to examine, photograph, administer treatment and perform such minor operative procedures as may be deemed necessary in the diagnosis of my foot problem.

(If the patient is a minor, the legal guardian must sign)

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 MEDICAL INFORMATION

To help us meet your health care needs, please complete the following questionnaire.

How painful is your condition? (Scale: 0 = no pain 10 = extremely painful)

add another past surgery/hospitalization

REVIEW OF SYMPTOMS:

Are you CURRENTLY experiencing any of the following:

FAMILY HISTORY: Has any member of your immediate family been treated for the following?

MEDICATIONS: Are you currently taking any medications? (Please ATTACH list if needed)

Add new Medication

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.