Patient Intake Form

HEALTH QUESTIONNAIRE

Name

Primary Care Physician

Physician Tel. #

Referred to this office by

What is the reason for your visit?

Is this condition due to an injury?

Yes No

If yes, provide date, time and place of surgery.

Please briefly describe how the injury occured.

Was this injury related?

Yes No

If yes, have you reported this injury to your supervisor?

Yes No

PAST MEDICAL HISTORY

Please list any medical conditions that you are currently being treated for.

Have you ever been hospitalized or been under medical care overnight?

Yes No

If, yes, please state the reason(s).

Have you ever had previous surgery?

Yes No

If yes, please list them.

Please list any known post-operative complications (delayed-healing, infection, anesthetic reaction, etc.)

FAMILY HISTORY

Please list medical illnesses in your family.

SOCIAL HISTORY

Marital Status

Single Married Separated Divorced Widowed

Whit whom do you current live?

Family Roommate Alone

Alcoholic beverages

Never Rarely Moderately Daily

Tobacco Use

Non-smoker Smoker Used to Smoke

Frequency (packs/day)

Year Quit

Other recreational drugs

Employer

Occupation

Work Address

Work Phone Number

SYSTEMIC REVIEW

Current Weight

Current Height

When was your last physical?

Are your immunizations up to date?

Yes No

For women only:

Number of pregnancies

Number of miscarriages

Source of information if other then the patient.

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 of person acquiring this information

Signature of Patient

Date

Signature of Parent/Guardian

Date

PATIENT INFORMATION

Name

Birthdate

Age

Sex

M F

Gender

Social Security #

Ethnicity

Driver's License #

Permanent Address

Street

City

State

Zip

Home Phone Number

Cell Phone Number

Email address

Preferred contact method

Phone call Email

Preferred Language

Emergency Contact

Phone Number

Relationship

INSURANCE INFORMATION

Insurance Provider

Policy Number

MEDICATION LIST

Name of Patient's Pharmacy

Pharmacy Address

Pharmacy Telephone

Known allergies

I have no allergies.

I am not currently taking any medications.

Add Medication

PAY BENEFITS, PAYMENT OF SERVICES: The information provided above is true to the best of my knowledge. I understand that professional fees are due at the time services are rendered. These include but are not limited to co-pays, deductibles, self-payment and all discount plan payments. I hereby authorize my insurance benefits to be paid directly to the physician: Stephen C. Wan, D.P.M., Chul Kim, D.P.M, Brian Park, D.P.M, Michael Bloch, D.P.M., Roland Carroll, D.P.M., Alexander Perez, D.P.M., and Jeffrey Tseng, D.P.M for the surgical and/or medical benefits, if any otherwise payable to me for his services. I understand that I am financially responsible for all balances that are not covered by my insurance plan. I also authorize Archstone Foot and Ankle Institute and the insurance company to release any information required to process my claims. If it becomes necessary to collect fees through the services of an attorney or collection agency, I understand my balance owed may increase.

Signed (Insured Person)

Date

MISSED APPOINTMENT POLICY

We thank you for choosing us as your healthcare provider. In order to give you and all our patients, the best possible care, we request you review our policy regarding missed appointments. A missed appointment is when you fail to show up for an allotted appointment time, without a phone call or cancellation notice of at least 24 hours. Please remember that we have reserved appointment times especially for you.

If you are unable to keep your scheduled appointment time, we request you please call our office at least 24-hours in advance in order to avoid a missed appointment fee. If you fail to give us notice, you will be charged a $20.00 missed appointment fee. This charge is not covered by insurance.

I have read and understand the policy stated above.

Patient/Guardian Signature

Date

Printed Name

PATIENT CONSENT FOR MEDICAL PHOTOGRAPHY

I consent for medical imaging to be made of me or my child (or for person whom I am a legal guardian). I understand that the information may be used and shown in my medical record and for purposes of medical education of medical professionals, staff and patients at medical conferences, in office and via electronic publication. By consenting to this medical photography, I understand that I will not receive payment from any party. Refusal to consent to photographs will in no way affect the medical care I will receive. Although these photographs will be used without identifying information such as my name, I understand that it is possible that someone will recognize me. By signing this form below, I confirm that this consent form has been explained to me in terms which I understand.

Patient/Guardian Signature

Date

Printed Name

I agree to the use of my image for medical records ONLY.

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

I acknowledge that I was provided with a copy of the Notice of Privacy Practices and that I have read (or had the opportunity to read if I chose so) and understood the notice.

Patient/Guardian Signature

Date

Printed Name

GENERAL CONSENT TO CARE

I, the undersigned, for myself or a minor child or another person for whom I have authority to sign, hereby consent to medical care and treatment, as ordered by an Archstone Foot and Ankle Specialist provider, on an outpatient/office visit basis. This consent includes my consent for all medical services rendered under the general or specific instructions of a provider or the designee under the direction of a physician, as deemed reasonable and necessary. I am aware that the practice of medicine is not an exact science and acknowledge that no guarantees have been made to me as to the result of treatments or examinations at Archstone Foot and Ankle Group.

Patient/Guardian Signature

Date

Printed Name

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