New Patient Registration Form


Please correct the errors described below.

Please complete this form upon your first visit and sign. Notify us at future visits if any of the information changes.

Mailing Address


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Add Medication


Add Allergies to Medication



  1. Payment of deductibles, co-pays, co-ins, or cash services is expected at time of service. We accept Cash, Credit, and Care Credit. Those left unpaid will be sent to collections, and you will be responsible for the fee's accumulated from our collection company. Invoices are sent out every 30 days. Any bounced check fee of $35.00.
  2. Twenty-four (24) hour is required for cancellation of all appointments. Failure to cancel appointment within this time frame or failure to show for a scheduled appointment will result is a $25.00 charge being added to your account.
  3. There will be a fee of $20.00 for all Paperwork that needs to be filled out by the doctor. This includes any forms given by your Employers, Insurance Company, and/or disability insurance.
  4. Having insurance is NO guarantee that services rendered will be paid for by your insurance. You will be billed for denied/non-covered/or unpaid services. It is ultimately the patient's responsibility to understand his/her insurance coverage and/or plans.
  5. It is YOUR responsibility to know what doctors or facilities are covered by your insurance policy. You will be expected to pay any services not covered by your insurance.
  6. Copies of all valid insurance cards are required in order for us to bill your insurance. If you do not have this at the time of your visit you may be requested to reschedule the visit until such time as you can provide proof of insurance coverage, or you may be asked to pay for your visit in full at the time of service.
  7. If your insurance requires a referral from your PCP to see a specialist, it is YOUR responsibility to obtain this and provide our office with a copy. If you do not have a copy of your referral you may be asked to reschedule your visit until the referral is obtained or you may be asked to pay for services in full prior to seeing the doctor.
  8. If your insurance company denied your claim because they need additional information from you or another one of your providers, it is YOUR responsibility to make sure your insurance company receives this information. If you do not provide this information to your insurance company and your claim remains denied, you will be expected to pay for these services. (Re-billing fee: I agree to pay a fee of $15 for every additional billing statement sent to me, after this statement, for which there will be no charge. This will be in effect, unless there is a prior payment arrangement made with Centennial Foot and Ankle.)
  9. Request for any/all medical records will be charged at $.60 cents a page and $3.00 for all X-ray images.

OTHER PATIENT RESPONSIBILITY Photo I.D. required this our way of making sure we are treating the correct patient. If the patient is a minor we will require photo I.D. of a parent/guardian. If you cannot provide this information, we will need to reschedule your appointment.

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.

If Patient is under 18, Parent or legal guardian to sign below

Your information will be encrypted.