Patient Forms

Patient's Last Name:

First Name:

Today's Date:

Patient's Address:

City:

State:

Zip:

Home Phone:

Cell Phone:

Date of Birth:

Social Security Number:

Gender:

Male Female

Shoe Size:

Height:

Weight:

Marital Status:

Spouse's or Parent's Name:

My Foot Problems are:

How long have you had the problem(s)

Days:

Weeks:

Years:

INSURANCE INFORMATION

Are you the insured:

Yes No

If no, Name of the Insured:

Primary Insurance:

Group #:

Policy #:

Effective Date:

Secondary Insurance:

Group #:

Policy #:

Effective Date:

COMPLETE THIS SECTION ONLY IF NAME OF INSURED IS DIFFERENT FROM PATIENT

Last Name:

First Name:

Gender:

Female Male

Insured's Address:

City:

State:

Zip:

Insured's Date of Birth:

Social Security Number:

What is the insured's relationship to the patient:

Please Complete This Section

Primary Care Physician

Email Address:

Pharmacy

Address:

City:

State:

Zip:

Phone:

Date of last visit:

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.

Patient Signature

Date field

Today's Date:

Due to Health Insurance Portability and Accountability Act (HIPPA) of 1996, the following information must be filled out by each patient annually.

I authorize Dr. Asia N. Jackson, DPM to release my medical or insurance information necessary to process my medical claims and coordinate or manage my healthcare.

Yes No

In the event a family member or caregiver attends your office visits and is the exam room at the time of your evaluation and/or treatment, I give Dr. Asia Jackson with Advanced Podiatry Associates and its physicians or employees my permission to discuss freely my condition, treatment, or diagnosis with that person.

Yes No

Does Dr. Asia N. Jackson, DPM have permission to send a copy of your treatment note to your Primary Care Physician per his/her discretion?

Yes No

Please provide the numbers below where we have consent to leave a message.

May we leave a message at your home?

Yes No

Home Phone:

May we leave a message at your work?

Yes No

Work Phone:

May we leave a message on your cell?

Yes No

Cell Phone:

May we leave a message on your pager?

Yes No

Pager:

With whom may we discuss or release information about your care, treatment or diagnosis?

Add another name

How Did You Hear About Us or Whom May We Thank For Referring You

Last Name:

First Name:

Address:

City:

State:

Zip:

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.

Patient/Parent/Guardian Signature

Date Signed:

Patient Name:

Your information will be encrypted.

Patient Forms

INSURANCE INFORMATION

COMPLETE THIS SECTION ONLY IF NAME OF INSURED IS DIFFERENT FROM PATIENT

Please Complete This Section

***How Did You Hear About Us or Whom May We Thank For Referring You***

How Did You Hear About Us or Whom May We Thank For Referring You