Welcome to Our Office

Patient Name

Date

Responsible Party's Name

Your Shoe Size

Cellphone

Telephone

Address

City

State

Zip Code

Date of Birth

Age

Sex

Social Security Number

Marital Status

Single Married Divorced Widowed Separated

Race

Hispanic

Yes No

Primary Language

Employer

Occupation

Employment Address

Work Phone

Name of Spouse (or Parent or Guardian)

Occupation

Employer (Spouse)

Employment Address

Work Phone

How were you referred to the office?

May we leave health information at the above telephone numbers?

Yes No

Medical Insurance

Yes No

Subscriber Name

Insurance Company Name

DOB of Subscriber

Insurance Address

City

State

Zip Code

Group Name

Group #

ID #

HMO

Yes No

Referral Needed

Yes No

Deductible Amount ($)

Co-Payment ($)

Medicare #

Medicaid #

PLEASE PROVIDE US WITH ANY UPDATED INSURANCE INFORMATION IF YOUR STATUS SHOULD CHANGE. THIS IS NECESSARY FOR US TO PROPERLY FILE YOUR INSURANCE CLAIMS. THANK YOU.

Due to the rising costs of billing, payment for professional services rendered is due and payable upon completion of each visit. We will submit to your insurance company, but we would like you to realize that payment from insurance companies varies. There may be some services that are not covered by your insurance company. You may be responsible for those non-covered services as well as any co-insurance due and deductible due. We are providers for many carriers and will accept assignment for them. However, you will still be responsible for any outstanding coinsurance, deductible not met, or any non-covered services. $25.00 CHARGE FOR APPOINTMENTS NOT CANCELED WITHIN 24 HOUR NOTICE TO OFFICE.

We invite you to discuss any questions you may have regarding our services or fees. We care and value you as our patient.

I authorize payment of medical benefits including Medicare to Podiatric Care of Northern Virginia. I promise to pay any outstanding balance to Podiatric Care of Northern Virginia in scheduled monthly payments, if needed, as established by the office manager. I have read all of the above.

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.

Date

Signature

What is your present foot problem?

How long?

Treatment, if any:

Family Doctor

Telephone Number

Address

City

State

Zip Code

Are you now or have been under a doctor's care during the past two years?

Yes No

If yes, explain:

Are you presently taking medicine?

Yes No

Add additional

Have you ever experienced any unusual or allergic reaction to medicine or other (ex: grass, metals, materials)

Yes No

If yes, explain:

Do you smoke?

Yes No

Packs per day?

# of Years Smoking?

# of Years Quit?

Other:

Family History

List the relationship of person(s) that have or had any of the following. Blood relatives only (mother, father, brother, sister, grandparents, etc.)

Heart Disease

Cancer

Arthritis

Diabetes

High Blood Pressure

Kidney Disease

Liver Disease

Overweight

Low Blood Pressure

Feet Problems

Others

Is there any other health information or general information we should be aware of:

Acknowledgment of Receipt of Notice of Privacy Practices

I acknowledge that I was provided a copy of the Notice of Privacy Practices by Podiatric Care of Northern Virginia and that I have read (or had the opportunity to read if I so chose) and understood the Notice.

Read our Notice of Privacy Practices here.

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 Name

Date

Parent or Authorized Representative (if applicable)

Signature

Your information will be encrypted.