New Patient Information

Please correct the errors described below.

INSURANCE INFORMATION

IN CASE OF EMERGENCY

The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Elite Foot and Ankle Clinic or an insurance company to release any information required to process my claims. I authorize the release of any previous medical records by fax, mail, or phone by either physician or hospital generated. I also hereby authorize the doctor and/or her assistants to initiate the diagnosis and treatment of my condition with x-ray, examination, or photographs of my condition as medically necessary.

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 Information

Please list any major events, hospitalizations, surgeries … etc.…

Add Additional Row

PERSONAL MEDICAL HISTORY

FAMILY HISTORY

Add new row

Add new row

Add new row

Add new row

Add new row

Add new row

SOCIAL HISTORY

Section 1: Tobacco

Section 2: Alcohol

Section 3: Recreational Drugs

Additional information

REVIEW OF SYSTEMS

Medications

Please list all medication you are currently taking including over the counter and vitamins (example: Tylenol 1 600mg tablet every 6hrs as needed)

Please list any/all Allergies (food, drug…etc…), please include your reaction

Add Additional Allergies

Acknowledgement of Recipt of Privacy Notice

I have received a copy of Elite Foot and Ankle Clinic’s Notice of Privacy Practice, which details how my personal health information may be used and disclosed as permitted under federal and state laws. I have read and understand the contents of the notice.

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.

Internal Use Only

If a patient’s representative refuses to sign acknowledgment of receipt of notice, please document the date and time the notice was presented to the patient and sign below

Consent to Enroll into Electronic Personal Health Record

Per Medicare Guidelines we are required to inform you that you are able to have access to your personal health information. To access your information please provide your email address. If you do not have your own, with your consent, we may use a family member’s email address. If no other email address is available to you, we are more than happy to assist you in opening a new email account

Your signature indicates your understanding and consent to being enrolled in our online patient portal that will allow you timely access to your electronic personal heath record.

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.

We now have the ability to email and / or text you, reminding you of your appointments. If you would like to receive this feature, please read the consent below and sign.

Consent to email and / or text message for appointment reminders and other healthcare communications:

Patients in our practice may be contacted via voicemail, email and / or text messaging to remind you of an upcoming appointment, and to provide general health reminders / information

I consent to receiving appointment reminders and other healthcare communications / information via voicemail, email and / or text from Elite Foot and Ankle Clinic.

The cell phone number that I authorize to receive voicemails, text messages for appointment reminders, and general health information is

I understand that this request to receive voicemails, emails and / or text messages will apply to all future appointment reminders / health information unless I request a change in writing.

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.

Your information will be encrypted.

Loading...