New Patient Form

Patient Information

Date

Legal Name

Address

City

State

ZIP

Phone Number

Email address

Gender

Male Female Other

Date of Birth

Status

Married Widowed Single Partner Minor

Spouse / Partner Name

Phone

In case of an Emergency

Name

Relationship

Contact Number

How did you hear about us?

Podiatric History

Reason for Today’s Visit

Duration

Location

Onset (How did it start)

What Makes it Worse

What Makes it Better

Treatments

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

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Medical History (List all your medical problems)

Past Surgery History / Date / Include Childbirth

Family History (medical problems)

Your Primary Care Physician (PCP)

Address

Phone

Review of Systems

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

Aids/HIV

Yes No

Allergies to anesthetics

Yes No

Allergies to medicine or drugs

Yes No

Anemia

Yes No

Angina

Yes No

Arthritis

Yes No

Artificial heart valves or joints

Yes No

Asthma

Yes No

Back problems

Yes No

Bleeding Disorders

Yes No

Cancer

Yes No

Chemical Dependency

Yes No

Chest pain

Yes No

Chronic Diarrhea

Yes No

Circulatory problems

Yes No

Clotting History

Yes No

Diabetes

Yes No

Ear Problems

Yes No

Epilepsy

Yes No

Eye problems

Yes No

Fainting

Yes No

Leg Cramps

Yes No

Gout

Yes No

Headache

Yes No

Heart Disease

Yes No

Hepatitis

Yes No

High Blood Pressure

Yes No

Kidney Problems

Yes No

Liver disease

Yes No

Low blood pressure

Yes No

Neuropathy

Yes No

Radiation treatment

Yes No

Rash

Yes No

Special Diet

Yes No

Stroker

Yes No

Swelling ankles, feet

Yes No

Tired Feet

Yes No

Tubercolosis

Yes No

Ulcers

Yes No

Varicose Veins

Yes No

Weight gain / loss

Yes No

Other

ALLERGIES

Adhesive/Tape

Yes No

Aspirin

Yes No

Anticoagulant Therapy

Yes No

Codeine

Yes No

Demerol

Yes No

Iodine

Yes No

Novocain

Yes No

Local anasthetics

Yes No

Penicillin

Yes No

Seafood

Yes No

Sulfa

Yes No

Other

Treatment Consent

(Print Name): I

Date of Birth:

hereby give my consent to give my permission to Dr. Costache / Dr. Melnick and the 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

Insurance

Who is responsible for the account?

Relationship to Patient

Health Insurance

Group #

Member ID #:

Date of Birth

SS#

Insurance disclaimer

"A benefit and / or authorization for appointment does not guarantee payment or actual eligibility. The payment of benefits is subject to all the terms, conditions, limitations and exclusions of the member's insurance contract at the time of service."

Payment insurance responsibility: Your health insurance company will only pay for services it determines to be "reasonable and necessary." The office will do everything possible to have all services and procedures previously authorized by your health insurance company, when prior authorization is required. It is possible that your health insurance company may deny a service is not included in your health insurance plan.

Beneficial Additive If my health insurance company denies the payment, I agree to be personally and fully responsible for the payment. I also understand that if my health insurance company makes the payment for the services, I will be responsible for any co-payment, deductible or co-insurance that is applied at the end of the service.

Signature

Date

Notice of privacy practices and HIPAA contact sheet

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.

Your Signature

Date

Your provider and/or staff will at times need to contact you. By filling out the information below we will be better able to serve you.

Patients name (please print)

Person completing this form

Responsible party

Written, Phone & Phone messages consent

To protect your privacy, we have developed a policy in leaving medical care information.

We will NOT leave messages with anyone except the patient, legal guardian or responsible party.

We will NOT leave any confidential information on an answering machine.

We will NOT leave any messages on a voice mail.

We will NOT release medical treatment information or medical records without written consent.

UNLESS WE HAVE YOUR WRITTEN PERMISSION TO DO SO

Please read below and consider carefully whom you authorize to have access to protected information regarding your care.

I, (indicate name below) give Cherry Creek Foot & Ankle Clinic my permission to speak with and/or leave phone messages regarding medical care and/or billing information with the following. I fully understand that this consent will remain valid until revoked on writing. Written documents include release of medical records and mailing of billing statement.

Name

My home/cell answering machine

Yes No

Initials

My office/work voice mail

Yes No

Initials

Fax billing statement

Yes No

Initials

Persons we can communicate with and share medical and billing information to:

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Patient Name

Date

Your information will be encrypted.