Patient Information Form

Patient Information

Last Name

First Name

Date of Birth

Social Security Number

At Least Last 4 Digits

Contact Phone

Email address

Address

City

State

Zip Code

Preferred Language

Insurance Information

Insurance Card/Information Upload

Add file

Please upload a file

Add secondary insurance

Responsible Party

Choose One

Self Other

Name

Date of Birth

Address

City

State

Zip Code

Preferred Phone Number

Relationship to Patient

Primary Care Doctor

Practice Name

Phone Number

Referring Physician

Phone Number

Emergency Contact Information

Name

Relationship to Patient

Cell Phone

Home Phone

Work Phone

Medical Information

Describe your foot/ankle problem today:

How long has it been bothering you?

Was this the result of an injury?

Yes No

If so, when, where, and how did the injury or accident occur?

Have you had other issues with your feet or ankles in the past?

Yes No

If so, please describe:

Add additional procedure

Shoe Size

Current Weight

Current Height

Add additional allergy

Have you had problems with local anestetics?

Yes No

Are you allergic to latex?

Yes No

Do you have diabetes?

Yes No

If yes, when were you diagnosed?

Have you ever been diagnosed with MRSA?

Yes No

If so, when?

Do you take insulin?

Yes No

Name of Physician that Manages Your Diabetes

Your physician's phone number

What was your latest blood sugar or A1C reading?

Add additional

Add additional procedure

Do you have artificial joints or implants?

Yes No

If yes, please explain:

Do you have a heart valve implant?

Yes No

Do you smoke?

Yes No

If yes, how many packs per day? How long?

Did you previously smoke?

Yes No

If yes, how many years?

Alcohol Consumption?

Yes No

How often?

1-2 Drinks/Week 1-2 Drinks/Day More than 2 Daily

Activity Level

Sedintary Light Moderate Very Athlete

Family History

Please check if a close blood relative has any of the following:

Heart Disease

Arthritis

Neurological Disorder

Bleeding Disorder

Stroke

Circulatory Problems

Bunions

Hammertoes

Flat Feet

Medications/Pharmacy Information

Add additional medication

Or, please upload a list of your medications.

Add file

Please upload a file

Pharmacy Name

Pharmacy Phone Number

Pharmacy Address

City

State

Zip Code

I hereby request medical treatment and authorize payment to Dr. Timothy L. Gardner, DPM.

I understand that I am responsible for any portion of my bill not covered by my insurance company and give Dr. Gardner's office the right to collect my balance within 90 days or I understand that I will be sent to a collections agency and possibly face legal action.

I hereby authorize the release of medical information for insurance claims purposes.

Disclaimer: By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature

Date

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