New Patient Form

Patient Registration: PLEASE FILL OUT ALL INFORMATION
(Click to select each data field to make an entry on each line, as needed. Blinking cursor doesn’t show in dark fields, so just begin to type. Do NOT use the “Enter” key. DO NOT USE ALL CAPS/CAPS LOCK. Do not type beyond the line. Click the appropriate Check Mark boxes. Use Drop-Down Arrows.)

Patient Information

Appointment Date:

Legal Name

Address

City

State

ZIP

Phone Number

Email address

Date of Birth

Spouse / Partner Name

Phone

In case of an Emergency

Name

Relationship

Contact Number

How did you hear about us?

Google/Web Family member Friend Referral

Podiatric History

Reason for Today’s Visit

Duration

Location

Onset

What Makes it Worse

What Makes it Better

Treatments

Height:

Weight:

Your occupation

Smoking

Yes No Quit (indicate date below)

If selected "quit" above, kindly indicate date below.

Alcohol Use

None Moderate Heavy

Previous Foot / Ankle problems / Trauma History with Dates

Primary Care Physician (PCP) Name:

Date Last Seen:

Address:

Phone

Add Medications

Review of Systems

Do you have or have you had any of the following: (check all that apply)

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ALLERGIES & Reactions

Add new row

Medical History (List all your medical problems)

Past Surgery History / Date / Include Childbirth

Family History (medical problems)

Additional comments about your foot conditions today:

Consent to Obtain Patient Medication History & Treatment Consent

Patient medication history is a list of prescriptions that healthcare providers have prescribed for you. A variety of sources, including pharmacies and health insurers, contribute to the collection of this history.
The collected information is stored in the practice electronic medical record system and becomes part of your personal medical record. Medication history is very important in helping providers treat your symptoms and/or illness properly and avoid potentially, dangerous drug interactions.

Date of Birth:

hereby, give my permission to allow my healthcare provider to obtain my medication history from my pharmacy, as well as my health plans and my other healthcare records from my other healthcare providers, as necessary. And, I, hereby, give my consent to Dr. Costache, Dr. Derickson, and the supporting medical staff, to administer and perform the procedures that the doctor deems medically necessary.

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.

Signature

Date

Health Insurance/Self-Pay

Who is responsible for the account?

Relationship to Patient

1.) INSURANCE OPTION:

INFORMATION ALREADY PROVIDED:

(If insurance has not yet been provided, please fill in the information below.)

Add new row

2.) SELF-PAY OPTION:

Self-Pay Payment Responsibility: I agree to be personally and fully responsible for the payment that is applied at the end of the service.

By signing below, you agree to all indicated on this page.

Signature:

Date

NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT

I acknowledge that I was provided a copy of or access to the Notice of Privacy Practices. I have read or had the opportunity to read and understand the HIPAA notice of privacy practices.

Patient’s Name:

Parent or Authorized Representative (if applicable):

Signature:

Date

NEW HIPAA REGULATIONS

As of October 2002, HIPAA (Health Insurance Portability and Accountability Act) Regulations require a consent form to be signed by all patients regarding patient confidentiality.

allow Dr. Costache, Dr. Derickson, and/or any staff member to leave information regarding myself:

Please mark each of the choices that are applicable:

Leaving the above information:

With my spouse, family member, and/or dependent, as listed on Page 1 of Patient Registration.

May list additional names with relations here:

On an answering machine/voicemail, which is from a listed phone number on my account.

About information regarding:

Radiology or Lab Results

Appointment Dates and Times

Accountant Information (insurance, billing, collection information via email or fax)

Signature

Date

DISCLAIMER: By typing your name in all of the designated signature areas, you are electronically signing these forms (all forms in this packet, which are part of, & included in, the Patient Registration process). You agree that your electronic signature is the legal equivalent of your manual signature on this application. . Please type/sign your name below to accept this digital signature.

Signature

Date

SCHEDULED APPOINTMENTS

We are aware that delays can happen, however, we try to keep all of our patients and our providers on time.

If a patient arrives 15 minutes or more, past their scheduled time, we will have to RESCHEDULE the appointment. Please call if you are running late or are not able to make it to your appointment. Thank you.

Your information will be encrypted.

New Patient Form

Patient Information

In case of an Emergency

Podiatric History

Review of Systems

ALLERGIES & Reactions

Consent to Obtain Patient Medication History & Treatment Consent

Health Insurance/Self-Pay

NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT

NEW HIPAA REGULATIONS

*SCHEDULED APPOINTMENTS*

SCHEDULED APPOINTMENTS