New Patient Form


Please correct the errors described below.

Dear Patient,

The information we ask for below is confidential and is to help us to carry out your treatment in the best possible way. If you are not sure about the answer to any question(s) please tell the Receptionist.

General Information

Phone Number(s}:

Insurance Information

Health Information

Health Information (cont'd)

Do you have or have you ever had:

I, the undersigned, hereby authorize payment of insurance benefits to the attending podiatrist (where applicable), for services rendered to the above-named patient, together with the release of any information to process the claim. I understand that I am responsible for the payment in the event that my insurance does not pay.

Your information will be encrypted.