New Patient Paperwork

• Please provide a copy of your current insurance cards.

• Co-Pay, Co-Insurance & Deductibles are expected at the time of service.

Patient Information

Last Name:

Date of Birth:

First Name:

Patient Gender:

Male Female

Middle Name:

Marital Status:

Address:

Race:

City, State, Zip:

Employer Name:

Home Phone#:

Address:

Cell Phone#:

City, State, Zip:

Social Security #:

Phone:

Email address:

Occupation:

How did you hear about our practice?

Family/PCP Physician:

Name:

Phone#:

Date last seen:

Pharmacy:

Name:

Street Name:

Phone#:

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

HOME Phone (including auto calls)

Appointment Information

Medical Information

CELL Phone (including auto calls)

Appointment Information

Medical Information

WORK Phone

Appointment Information

Medical Information

With another Person(s):

Appointment Information

Medical Information

Email or Patient Portal:

Appointment Information

Medical Information

Mail

Appointment Information

Medical Information

Emergency Contact:

*****Please list name of someone not living in your household*****

Name:

Relationship to Patient:

Phone#: Wk.

Hm.

Do you have an advance care plan or surrogate decision maker?

Yes No

Name of custodian of document:

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 Cards/Documentation must be given to front desk at time of service ***

Guarantor Information:

(Person responsible financially and/or patient is a minor)

Last Name:

First Name:

Middle Initial:

Address:

City, State, Zip:

Home Phone#:

Cell Phone#:

Relationship to Patient:

Date of Birth

Will this treatment be done as a result of:

• Workers Compensation Injury:

Yes No

Date of Injury

WC Claim #:

Managed Care Organization:

Claims Representative:

Phone #:

• Auto/Personal Accident:

Yes No

Date of Injury

Claim #:

Auto/Home Owners Insurance:

Claims Representative:

Phone #:

Health Insurance:

Primary Insurance:

Referral Required

Yes No

Policy/ID #:

Group #:

Insured/Subscriber:

Relationship to Patient:

Social Security #:

Date of Birth:

Insured Employer:

Secondary Insurance:

Referral Required

Yes No

Policy/ID #:

Group #:

Insured/Subscriber:

Relationship to Patient:

Social Security #:

Date of Birth

Insured Employer:

INSURANCE AUTHORIZATION/ASSIGNMENT (PLEASE READ & SIGN)

I hereby authorize the physician to furnish information to my insurance carrier concerning my condition and treatment. I hereby assign to the physician all payments for medical service rendered to my dependent or myself. I understand that I am responsible for any amount not covered by my insurance carrier. I agree to be held responsible for collection processing fees that may be added to my account if collection action occurs.

Signature

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

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 MEDICAL INFORMATION

What condition(s) are you being seen for today?

NONE OF THE ABOVE

OTHER:

NONE OF THE ABOVE:

OTHER:

NONE OF THE ABOVE

OTHER:

Please SELECT if you have been HOSPITALIZED for any of the following:

NONE

Diabetes

Trauma

Blood Clot

Wound

Diverticulitis

Dehydration

Pneumonia

Infection (Type):

OTHER:

Height:

Weight:

Shoe Size:

Mens:

Womens:

Smoker?

Yes No

If yes, how long?

How many packs a day?

Quit

Alocohol Use?

Yes No

If yes, how many drinks per week?

Drug use?

Yes No

If yes, type?

Marijuana

Illegal Prescription

Other

Smoke Less Tobacco?

Yes No

If yes, how long?

How often?

Quit

Have you gotten a flu vaccine this season?

Yes No

Date:

Have you gotten a pneumonia vaccine within the last 5 years?

Yes No

Date:

List Prescription Medications Currently Taking: (Please ATTACH List)

Name of Medication

Strength

Dosage

Frequency

Add another medication

NONE AT THIS TIME

OTHER :

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

(Please check all that apply and select the appropriate family member.)

Arthritis

Father

Mother

Brother

Sister

Son

Daughter

Cancer

Father

Mother

Brother

Sister

Son

Daughter

Diabetes

Father

Mother

Brother

Sister

Son

Daughter

High Blood Pressure

Father

Mother

Brother

Sister

Son

Daughter

Heart Disease

Father

Mother

Brother

Sister

Son

Daughter

Stroke

Father

Mother

Brother

Sister

Son

Daughter

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:

Your information will be encrypted.