New Patient Registration Form

Patient Registration Form

Select Location:

Bellevue Commons (1200 112th Ave NE, STE B250 Bellevue, WA 98004)

Swedish Issaquah (751 NE Blakely Dr. 3rd FL Issaquah, WA 98029)

Swedish Redmond (18100 NE Union Hill Rd Redmond, WA 98052)

Swedish West Seattle (4100 SW Alaska St. STE B Seattle, WA 98116)

Cabrini Tower (901 Boren Avenue #711 Seattle, Washington 98104)

Appointment Date

First Name

Middle Initial

Last Name

Address

City

State

Zip

Preferred Language

English Other

If other, please specify

SSN

Date of Birth

Phone

Cell Work Home

Alt. Phone

Cell Work Home

Contact preference

Phone Alt. Phone Email

Gender

Race

American Indian Asian African American Caucasian Pacific Islander Other

If other, please specify.

Marital Status

Single Married Divorced Widowed

Ethnicity

Hispanic Non Hispanic Other

Employer

Occupation

Emergency Contact Information

Name

Relationship

Phone

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

Responsible Party

Address

Primary Care Physician

Who referred you to our office?

Workers Compensation Claim

Yes No

Reason for Visit

Primary Insurance

Secondary Insurance

Address

Insurance ID

Group ID

Subscriber

Relationship

I give my consent for services to be rendered by Podiatry Associates NW. I acknowledge that I am financially responsible for all charges and authorize my insurance benefits to be paid directly to my physician. I authorize Podiatry Associates NW and any healthcare organization or insurance company to release information necessary to process this claim.

Note: If the patient is under 18 years of age, the accompanying parent is financially responsible.

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.

Signature

Date

Name and Relationship (if other than patient)

Patient Health History

If other, please specify

Past Surgical History/Hospital Stays

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Family Medical History (Please indicate affected relatives)

Peripheral artery disease

Reaction to anesthesia

Stroke

History of blood clots

Heart disease

Cholesterol

High blood pressure

Kidney Trouble

Rheumatoid arthritis

Drug Addiction

Diabetes

Cancer

List medications

Allergies

Do you currently use or consume the following?

Caffeine

Yes No

Cups per day

Tobacco

Yes No

Packs per day

Alcohol

Yes No

Amount per week

Recreational Drugs

Yes No

Please specify

Patient Name

Date of Birth

Signature

Date

Name and Relationship (if other than patient)

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF HEALTH INFORMATION PORTABLILITY AND ACCOUNTABILITY ACT

Patient Name

Date of Birth

By my signature below, I acknowledge that I received a copy of the Notice of Privacy Practices for Podiatry Associates NW.

This authorization grants permission to the Designated Party(ies) named below to exchange my private medical information with Podiatry Associates NW, and any authorized representative thereof, without restriction in terms of content, purpose, or means of transmission. This authorization includes, but is not limited to: making or confirming appointments; accessing any and all imaging, laboratory, or test information; access to telephone communication and answering machine messages as well as other common means of communication; be made aware of my diagnosis, prognosis, and treatment plans; direct discussion of my health with my doctor or other provider; and have access to my financial information as it relates to my health.

Add new row

Signature

Date

Name and Relationship (if other than patient)

Your information will be encrypted.