New Patient Registration Form

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

Date

Referred By

Patient's First Name

Middle Initial

Last Name

Birthdate

Gender

Male Female

Social Security Number

Mailing Address

Street Address

Apt/Unit #

City State

Zip

Email address

Marital Status

Single Married Partner Widowed

Patient's or Parent's Employer

Work Phone

Employer Address

Occupation

Spouse or Parent's Name

Emergency Contact Name

Relationship

Phone

Name of Primary Care Doctor

Would you allow our office to send clinical notes to this physician

Yes No

Date of Last Visit

INSURANCE/PAYMENT INFORATION

Primary Insurance

Phone Number

ID #

Group #

Policy Holder

Policy Holder Date of Birth

Policy Holder SS#

Relationship to Patient

Secondary Insurance

Phone Number

ID #

Group #

Policy Holder

Policy Holder Date of Birth

Policy Holder SS#

Relationship to Patient

Tertiary Insurance

ID #

Policy Holder

Policy Holder Date of Birth

Relationship to Patient

Pharmacy Name

Phone Number

What is your complaint/reason for today's visit

Have you received treatment for this issue?

Yes No

Date of unset?

Is your visit related to?

An accident?

Yes No

An injury?

Yes No

Workers Compensation?

Yes No

If your answer is YES to the above, please describe how, when and where the accident/injury occured

Worker's Comp: Was C-4 form filled out?

Yes No

Are your represented by a lawyer?

Yes No

MEDICATIONS

Add Medication

ALLERGIES TO MEDICATION

Add Allergies to Medication

Surgery history

Do you have any type of

Metal Implants

Pacemaker

Defibrillator

Plate/Screws/Rods

If Other, please specify

Are you currently pregnant?

Yes No

Diabetes: Are you a Diabetic

Yes No

Last HbA1c

Height

Weight

SOCIAL HISTORY

Do you Smoke?

Yes No

If so, For how long?

Former Smoker

Yes No

Do you use Alchohol?

Yes No

Quantity?

Per

Recreational Drug Use?

Yes No

Drugs used

Crack/Cocaine

Heroin

Marijuana

Methanphetamines

Other

If Other, please specify

PATIENT RESPONSIBILITY

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.
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.
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.
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.
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.
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.
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.
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.)
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.

Patient Name

Date

Patient Signature

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

Your information will be encrypted.