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

Single Married Divorced Widowed Separated

Address:

Race:

City, State, Zip:

Occupation:

Home Phone#:

Full Time Part Time Retired Disabled

Cell Phone#:

Employer:

Work Phone#:

Address:

Social Security #:

City, State, Zip:

Email address:

Phone:

Whom may we thank for referring you to our practice?

Family/Friend

Physician Referral

Website

Insurance

Other

If other, please specify.

Family/PCP Physician:

Pharmacy:

Name:

Address:

City, State, Zip:

Phone#:

Date last seen:

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

Appointment Information

Medical Information

Phone (including auto calls)

Home

Cell

Work

Home

Cell

Work

TEXT / Email / Patient Portal:

Send Via Mail

With another Person(s):

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

Emergency Contact:

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

Name:

Relationship to Patient:

Phone#:

Home

Cell

Work

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

Do you have a first report of injury?

Yes No

Physician of Record

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, 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.

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

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

Describe your foot/ankle problem (example: right ankle pain):

When did this begin?

Was there an accident or injury?

No Yes

Please decsribe:

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

Type of pain

Burning

Tingling

Sharp

Dull Ache

Shooting

Stabbing

Numbness

Throbbing

When does the pain occur?

Standing

During walking

After walking

During sports

With shoes

Without shoes

Worse with activity

Better after activity

ALWAYS

What makes the pain/condition better (Example: rest, icing, medications, etc.)?

Height:

Weight:

Shoe Size:

Men's

Women's

Smoker?

Yes No

If yes, how long?

How many packs a day?

Quit

Vaping?

Yes No

If yes, how long?

How often?

Quit

Alocohol Use?

Yes No

If yes, how often?

Weekly

Occasionally

Rarely

Drug use?

Yes No

If yes, what type??

Marijuana

Illegal Prescription

Other

Illegal Prescription, specify type:

If other, please specify.

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:

Any other medical problems not listed above:

NONE OF THE ABOVE

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

NONE

Diabetes

Trauma

Blood Clot

Wound

Diverticulitis

Dehydration

Pneumonia

REVIEW OF SYMPTOMS: Are you CURRENTLY experiencing any of the following:

GENERAL

Chills

Fever

Unexplained Weight Gain

Unexplained Weight Loss

EYES

Eye symptoms

EARS/NOSE/THROAT/MOUTH

Ear Symptoms

Nasal Symptoms

Throat/Mouth Symptoms

RESPIRATORY

Shortness of breath

Cough

Congestion

Changes in appetite

Constipation

Diarrhea

Indigestion

Nausea

Ulcers

Vomiting

Urinary frequency

Excessive urination

Pain with urination

MUSCULO

History of falls

Leg cramps

Muscle aches

Tenderness

SKIN

Skin symptoms

Hair symptoms

Nail symptoms

NEUROLOGIC

Difficulty with balance

Headache

Lightheadedness

Restless leg syndrome

Stroke

PSYCHIATRIC

Anxiety

Insomnia

Memory loss

Mood changes

ENDOCRINE

Dry Skin

Hair loss

Excessive sweating

Excessive thirst

Thyroid problems

HEMA/LYMPH

Excessive bleeding

Bruising

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

MOTHER

FATHER

GRANDMOTHER

GRANDFATHER

Arthritis

High Blood Pressure

Cancer

Heart Disease

Diabetes Type I

Diabetes Type II

UNKNOWN

MEDICATIONS: Are you currently taking any medications?

NONE AT THIS TIME

Name of Medication

Strength

Dosage

Frequency

Add another medication

ALLERGIES: Please CHECK any of the following to which you’ve had ALLERGIC REACTIONS to:

OTHER :

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.