New Patient Paperwork

NEW PATIENT REGISTRATION FORM

Last Name

First Name

Street Address

City

State

Zip

Phone Number

Social Security #

Birth Date

Gender

Marital Status

Employer

Work Phone

Occupation

Person Responsible for Insurance/Account (if other than self):

Relationship

Birth Date (if other than self)

Primary Insurance

Policy Number

Copay:

Group Number

Secondary Insurance

Policy Number

Group Number

Referred By (check one)

Website Google Facebook Insurance Friend Other Doctor

If doctor, please provide name

Whom may we thank for referring you?

Name of Primary Care Physician

Phone

Date of Last Visit with Primary Care Physician

Pharmacy

City

Street

Emergency Contact

Phone

AUTHORIZATION FOR SHARING OF PROTECTED HEALTH INFORMATION

Preferred contact phone number

May we leave a detailed voicemail?

Yes No

The providers/staff of First Choice Podiatry may discuss my medical history/condition with the following:

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I do NOT want my personal health information shared with anyone

MEDICAL HISTORY FORM

Patient Name

Height

Weight

Shoe Size

Have you ever received treatment from a previous podiatrist?

What is the reason for your visit today?

Any past foot/ankle surgery or problems? If yes, please list

PLEASE ANSWER THE FOLLOWING

1. Do you have AIDS, HIV, or Hepatitis?

Yes No

2. Do you take a blood thinner or aspirin?

Yes No

3. Females: are you pregnant?

Yes No

4. Smoker (Please select)

Everyday Smoker Former Smoker Non-Smoker

5. Do you have diabetes?

Yes No

If yes, select type

Type I Type II

Controlled By

Insulin Orals Diet

6. Do you drink alcohol?

Yes No

If yes, how much (daily, weekly, monthly)?

7. Do you vape?

Yes No

Do you use illicit or recreational drugs?

PAST MEDICAL HISTORY – Please check all that apply:

FAMILY HISTORY: Please list any medical history (diabetes, cancer, high blood pressure, etc)

Mother

Father

Sister

Brother

MEDICATIONS

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ALLERGIES

Aspirin

Yes No

Codeine

Yes No

Iodine

Yes No

Latex

Yes No

Local Anesthesia

Yes No

Sulfa

Yes No

Penicillin

Yes No

Other

SURGICAL HISTORY

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FINANCIAL POLICY

PLEASE READ AND SIGN THE FOLLOWING FINANCIAL POLICY:

We will work with most insurance companies. However, payments for services rendered are your responsibility. If you have an HMO or POS plan requiring a referral, you must have a referral with you at that visit. You are responsible for co-pays, deductibles, and/or co-insurance under the terms of your insurance plan. All applicable co-payments, deductibles and co-insurance, and/or non-covered services are due at time of service. These amounts are estimates provided by your insurance company based on the insurance contract. Once the claims have been processed by your insurance company, there is a possibility that you may end up receiving a balance statement or a refund check.

You must notify the office of any insurance changes and authorization/referral requirements. In the event the office is not notified, you will be responsible for any charges denied.

There are no refunds or exchanges for supplies and/or medical equipment purchased in the office. All sales are final. Unfortunately, not every supply prescribed or recommended works for all patients. However, we strive to make every effort to have a satisfactory outcome.

There is a $30 fee for no-call/no-shows or appointment cancellations made less than 24 hours in advance.

I give First Choice Podiatry permission to treat me, request information from other physicians regarding my foot and ankle conditions and bill my insurance. Failure to pay bills promptly can result in legal actions to achieve collections. All collections and legal fees are the responsibility of the patient. A fee of 30% or greater may be addended to the bill if we are forced to take the account to collections. If you do not have insurance, payment in full is due on the day of service.

I have read and understand this form and all the information I provided is correct.

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

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