Patient Forms

ACTIVE MEDICATIONS – Please list any medications you are currently taking including any over the counter and vitamins.

If yes, please list your allergy below:

YOUR MEDICAL HISTORY

Have you ever had any of the following medical conditions:

FAMILY MEDICAL HISTORY

Has anyone in your family had/have any of the following medical conditions listed above? If yes, please list:

ACKNOWLEDGMENTS

Insurance/Billing

I understand that payment for professional services rendered is due and payable upon completion of each visit. I further understand that there will be some services that may not be covered by my health insurance and that I will be responsible for those non-covered services along with any copay, co-insurance and deductible due.

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.

Late Cancel/No-Show Fee

I understand I will be assessed a $25.00 fee for any appointment in which I cancel/no-show without providing notice within 24 hours.

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 it if I so choose and understand the notice.

Release of Information

I hereby authorize Podiatric Care of Northern Virginia to discuss my information whether relating to my care or financial responsibility to the below listed person(s):

I have read and understand all of the above and have completed this form to the best of my knowledge.

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.