New Patient Forms

Patient First Name:

MI:

Last Name:

Sex:

Male Female

Preferred Name:

Date of Birth:

Social Security #:

Marital Status:

Single Married Divorced Separated Widowed

Mailing Address:

City:

State:

Zip:

Physical Address:

City:

State:

Zip:

Home Phone #:

Cell Phone #:

Work Phone #:

Preferred communication:

home phone,

cell

work #

text

none

Email address:

Name of Primary Care Provider:

Pharmacy:

Employer:

Occupation:

Spouse:

DOB:

Social Security #:

Spouse Address:

City:

State:

Zip:

Spouse Employer:

Work Phone #:

If someone other than the PATIENT is responsible for payment, complete the following:

Name of responsible party:

Relationship to patient:

Spouse Address:

City:

State:

Zip:

Home Phone #:

Cell Phone #:

Work Phone #:

Birthdate:

Social Security #:

Employer:

How do you intend to pay?

Cash

Check

Visa/MasterCard

Insurance

Other

If Other, please specify:

Primary Insurance:

Phone #:

Name of insured:

DOB:

SSN:

Policy #:

Group #:

Address:

City:

State:

Zip:

Secondary Insurance:

Phone #:

Name of insured:

DOB:

SSN:

Policy #:

Group #:

Address:

City:

State:

Zip:

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 Signature:

Date:

PATIENT AUTHORIZATION TO LEAVE MESSAGES ON ANSWERING MACHINE/VOICEMAIL AND/OR WITH FAMILY MEMBERS AND FRIENDS AND TO DISCLOSE HEALTH INFORMATION TO FAMILY MEMBERS AND FRIENDS.

Patient Name:

Date of Birth:

I hereby authorize all of G. Jason Wilks, DPM, PC/Wilks Advanced Foot Care, office staff, healthcare providers, and any agents or independent contractors acting at and under the direction of same to leave a message regarding appointment reminders, test results, or diagnostic results with a designated family member and /or on my answering/voicemail and to disclose any health information to designated family members.

Authorization to leave message on answering machine/voicemail:

Yes No

Authorization to use text for provider review

Yes No

Authorization to use email for provider review and to receive medical educational information

Yes No

Authorization to leave message with designated names listed below:

Add authorized person

Authorization to discuss all health information with designated names listed below:

Add authorized person

RECEIPT OF NOTICE OF PRIVACY PRACTICES WRITTEN ACKNOWLEDGMENT FORM

I have received a copy of G. Jason Wilks, DPM, PC’s/Wilks Advanced Foot Care Notice of Privacy Practices.

Signature:

Date:

If you are signing as the patient’s guardian or legal power of attorney (documentation required):

Name:

Describe Authority:

Patient Name:

DOB:

Please provide the additional information which is required for federal standards. All information provided on this form will be kept confidential.

1. Primary Language (i.e. English, Spanish, Sign Language, etc.)

If Other, please specify:

3. Ethnicity

Do you consider yourself to be Hispanic or Latino according to the definitions below?

Hispanic or Latino/Spanish Non Hispanic or Latino Patient Declined State Prohibited

DECLINE: By checking this box, I hereby decline to provide the above information.

Patient Signature or Patient Representative Signature

Date:

Name (if signing on patient’s behalf)

(Power of Attorney paperwork must be provided)

Add file

Please upload a file

OFFICE AND FINANCIAL POLICY

G. Jason Wilks, DPM, PC/Wilks Advanced Foot Care would like to inform you of our office and financial policies. Please do not hesitate to ask for further explanation if there is anything you do not understand.

Registration - We ask that you accurately complete the Patient Information Form. You will be asked to update your information on a regular basis. A copy of your current insurance card will be kept in your chart. Please be sure to have the most current insurance card and information available for your appointments.

Insurance and Payment - Payment is expected at the time of service (copays, deductibles, & non-covered services). We accept cash, money order, check or credit card. (Visa, MasterCard, Discover) Financial arrangements, if necessary, must be made before seeing the doctor. Your financial responsibility and payment will depend on the complexity of the scheduled services and if the doctor is a participating provider with your insurance plan.

Insurance is billed as a courtesy to our patients and does not release the patient from payment responsibility.

We allow 45 days for insurance to make payment and then payment responsibility is transferred to the patient.

Any surgical procedure that is to be schedule for self-paying patient must be paid in full one week prior to the surgery.

We charge a $100 cancellation fee for any surgical procedure that is cancelled with less than one weeks’ notice.

Regardless of insurance coverage - The patient is ultimately responsible for payment. Accounts are assigned to our collection services from the date of service if payment arrangements have not been made. I understand that delinquent accounts may be assigned to credit reporting collection service, Southern Oregon Credit Services, and there will be a $50.00 collection fee. Also, if it becomes necessary to assign collections on any amount owed on this or subsequent visits; the undersigned agrees to pay for all costs and expenses, including attorney fees. Non-covered services are the responsibility of the patient/guardian.

Returned Checks - A $25.00 service charge fee will be assessed for every check returned to us. The returned check plus the service charge fee must be paid in cash within five business days.

Appointment Cancellation – Reserve the right to charge a $25.00 fee for any appointment that is missed (no show) or cancelled with less than 24 hours notice. Your insurance company does not cover this fee. We reserve the right to discharge patient with 3 “no shows”.

Patient Representatives - If you are unable to handle your own financial affairs, appoint someone to assist you. Advise the office with the name of the person you have assigned to assist with your finances, so that financial confidentiality is maintained.

I have read the above office and payment policy and understand that regardless of any insurance coverage I may have, I am responsible for payment of my account. I hereby authorize the doctor to release information necessary to secure payment. This will ensure that responsible patients will not be penalized to cover costs incurred by others.

Patient/Representative Signature:

Date:

Name:

DOB:

Are you:

new patient transfer of care from another podiatrist re-establishing care with Dr. Wilks

How did you hear about Dr. Wilks office:

Primary Care

Google

Another Patient

Facebook

Yellow Pages

other

If other, please specify:

Please state, in your own words, your reason(s) for coming into my office today:

Please list any surgical procedures you have had done:

Signature of Patient/Guardian:

Date:

MEDICATIONS & ALLERGIES

Patient Name:

Date of Birth:

If you have a current list of your medications, we can just make a copy.

Add file

Please upload a file

Please list any prescription medications, over the counter medications, vitamins, herbs or nutritional supplements that you are now taking. Please include the dosage amount and the times per day you take them.

Please be as specific as possible

Add medication

Allergies:

Please include reaction you have to the allergy and the severity of it.
C= Critical S=Severe MO=Moderate MI=Mild

Add allergy

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