The following information is very important to your health. Please be complete.
CURRENT FOOT/ANKLE PROBLEM
Please check only what applies for personal or family medical history of any of the following:
ILLEGAL DRUG USE
I certify that the above information is true and correct to the best of my knowledge I give my permission for John Murphy, DPM to examine, photograph, administer and perform such minor operative procedures as may be deemed necessary in the diagnosis and/or treatment of my foot and/or ankle problems.
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.