Patient Update

Please correct the errors described below.

Patient Information

Emergency Contact


We accept most insurance, This is your responsibility to find out if we are providers for your insurance.

Please present your insurance cards at the front desk to be copied.

Updated Medical Health History

Medical History



Please provide us with an update of ALL medications you are taking. (If you have a written list, we can copy it to avoid your having to fill this section out)

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Family History

Please check if positive

Authorization to Treat

I understand that the information provided on this form is true and correct to the best of my knowledge.

  • I request that payments of authorized benefits be made on my behalf for any services furnished by Arp Foot & Ankle Clinic.
  • I authorize any holder of information about me to release any information needed to determine these benefits or the benefits payable to related services to the insurance agent.
  • I recognize my financial obligation of any coinsurance, co-pays or deductibles and non-covered services that may be required. There is a $25.00 no-show fee for missed appointments or appointments cancelled within the 24 hour notice period.
  • I hereby give permission to Arp Foot & Ankle Clinic and any qualified staff to evaluate, diagnose and treat my foot and/or ankle condition as may be deemed 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.

Your information will be encrypted.