First Visit Intake Form

Patient First Name:

Middle Initial

Last Name:

Age:

Date of Birth

Local Address

City

State

Zip

I am here month of:

To:

Vacation

Away

Address

City

State

Zip

Home Phone

Work Phone

SS #

Email address

Cell #

Place of Employment

School Name

If this visit is for an injury, was it due to an auto accident or job-related injury?

Yes No

Add new row

Had you had previous foot treatment?

Yes No

If yes, Please Explain

How did you hear about our services?

Medical Doctor

Address

Date of Last Visit

Pharmacy Name

Address

Telephone

Fax

Have you had previous surgery?

Yes No

What Type?

Do you have to be pre-medicated with antibiotics before having dental work done?

Yes No

Height

Weight

Blood Pressure

if (Other Antibiotics), Please indicate

if (Other Medications), Please indicate

if (Other), Please indicate

Contact in case of emergency

Phone Number

PRIMARY INSURANCE

Insurance Co. Name

Policy Number

Provider Support Phone (usually found on back of I.D. card)

Date of Retirement

If NO, please complete section below:

Policy Holder Legal Name

Policy Holder DOB

Policy Holder Address

City

State

Zip

If other, please specify

SECONDARY INSURANCE (if applicable)

Insurance Co. Name

Policy Number

Provider Support Phone (usually found on back of I.D. card)

Date of Retirement

If NO, please complete section below:

Policy Holder Legal Name

Policy Holder DOB

Policy Holder Address

City

State

Zip

If other, please specify

Parent / Spouse Name

SS #

Date of Birth

Parent / Spouse Place of Employment

If other than patient, send statements to: (Name, Address, Phone #)

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 / Signature

Date

FOR OFFICE USE ONLY

Chief Complaint

Onset, Duration & History

Trauma

Medication

Social Hx: Alcohol?

Yes No

How Often?

Past or Current Drug Use

Yes No

Family Hx

Diabetes

Arthritis

Cardiac

Other

Psychiatric (Orientation/Mood)

* PLEASE ALLOW 48 HOURS (2 BUSINESS DAYS) FOR PROCESSING *

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First Visit Intake Form

FOR OFFICE USE ONLY

***** PLEASE ALLOW 48 HOURS (2 BUSINESS DAYS) FOR PROCESSING *****

FAMILY FOOTCARE GROUP, LLP

* PLEASE ALLOW 48 HOURS (2 BUSINESS DAYS) FOR PROCESSING *