Patient Update

Patient Information

Patient First Name

M.I.

Last Name

Sex

Male Female

Date of Birth

Marital Status

Mailing Address

Apt. #

City

State

ZIP

Primary Phone

Secondary Phone

Employer

Phone Number

Email address

Would you like access to your patient portal?

Yes No

Emergency Contact

Name

Phone

Relationship

Insurance

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

Who is your family physician?

When was the last time you saw him/her?

Preferred Pharmacy

Medical History

Smoking status

Current smoker Quit Never

Allergies

Please list

Medications

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)

Add new row

Family History

Please check if positive

Mother

Diabetes

Arthritis

Hypertension

Heart Disease

Father

Diabetes

Arthritis

Hypertension

Heart Disease

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.

Patient or Authorized Signature

If not patient, state relationship

Date

Your information will be encrypted.