New Patient Information

Name

Date

Address

City

State

Zip Code

Home Telephone

Cell Telephone

Date of Birth

Age

EMPLOYER

Employer Name

Address

Work Telephone

Occupation

SPOUSE / GUARANTOR

Name

Date of Birth

Employer Name

Employer Address

Work Telephone

Occupation

Referred By

Doctor

Friend

Telephone Book

Outdoor Sign

Insurance Delivery

Internet

Other

If other, Please specify

INSURANCE INFORMATION

Primary Carrier:

Insurance Co.

Insured

Id #

Other Carrier

Insurance Co.

Insured

Id #

ALL CHARGES INCURRED ARE DUE AND PAYABLE AT THE TIME OF THE VISIT UNLESS PRIOR ARRANGEMENTS HAVE BEEN MADE.

I hereby give my permission for the doctor to render the proposed Podiatric examination and treatment. I understand that I am financially responsible to the Physician for all charges incurred by me or my dependents. I authorize the release of any medical information necessary to process any claim and request payment of insurance benefits due to be paid to the Physician supplying the service. I authorize the use of this form on all of my insurance submissions. I authorize my doctor to act as my agent in helping me obtain payment from my insurance Companies. I permit a copy of this authorization to be used in place of the original.

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 / Insured / Signature

Date

Patient History Information

Other

Family Physician

Name

Address

City

State

Zip

Telephone #

Physician last seen: (Month/Year)

Medications presently taking

Reason

If yes, any complications?

In Case of Emergency, contact: (other than spouse)

Name

Relationship

Address

Telephone #

Foot Health Information

What is your foot problem?

When did it begin?

How have you treated your problem so far?

If yes, Name

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's Name / Signature

Date

Your information will be encrypted.