Patient Registration

Demographic Information

Name:

Gender

M F

Date of Birth

Address

City

State

Zip

Home Phone #:

Work Phone #:

Cell Phone #:

Marital Status

Single Married Divorced Widowed Partner Legally Separated

Emergency Contact:

Relationship:

Cell Phone #:

E-Mail Address:

Primary Spoke Language:

Employment Status:

Full-Time Part-Time Not Employed

Student Status:

Full-Time Part-Time Not Employed

Race:

American Indian or Alaska native

Black or African America

Native Hawaiian or other Pacific Islander

White

Hispanic/Latino

Asian

Unknown

Ethnicity:

Hispanic or Latino Not Hispanic or Latino

Primary Care Physician:

Referred by

Vascular Surgery:

Neurologist:

Cardiologist:

Endocrinologist:

Nephrologist:

Rheumatologist:

Pharmacy:

Pharmacy phone #:

***Please describe your foot/ankle problem ( include date of injury if applicable) ***

How long has the problem been present ?

Have you had any treatment or taken anything for it?

Have you seen someone for this already?

No Yes

Whom?

Have you had any prior foot/ankle problems?

No Yes

If yes, please describe:

ALLERGIES

Please check all allergies:

Medications

Foods

Tapes or Topical Skin Sensitivity:

Other:

If Medications is select, specify:

If Foods is select, specify:

If Tapes or Topical Skin Sensitivity is select, specify:

If Other is select, specify:

MEDICATIONS

Please list all medications and the dosages

Add Medications

Personal Medical History:

** Check those that apply to you now or have applied to you in the past **

SURGICAL HISTORY

Surgical Procedures/Serious Injuries/Illnesses

Has any family member had any of the following ( please indicate relationship)

Cancer:

Diabetes:

Heart Trouble:

High Blood Pressure:

Kidney Disease:

Mental/Emotional Disease:

Tuberculosis:

Stroke:

Arthritis:

Emphysema:

Blood Clots:

Other:

PATIENT INFOMATION

Do you smoke currently?

No Yes

How may packs per day?

For how many years?

Have you smoked previously?

No Yes

When did you quit?

Number of Caffeine drinks per day?

Amount of alcohol consumed per week

For women only: Are you pregnant?

No Yes

How many months?

Please complete the following:

Height:

Weight:

Shoe Sizes:

Occupation:

Is there any other information you would like us to be aware of

No Yes

Is there any other information you would like us to be aware of

**Please circle off all that currently apply to you **

Neurological:

Burning in feet, tingling in feet or toes

Numbness

Tremors

Psychiatric:

Addiction

Attempted Suicide

Depression

Memory Loss

Panic Attacks

I hereby authorize direct payment of surgical and medical benefits on my behalf to the provider of these services that I would otherwise be payable to me if I did not make this assignment. I understand that I am personally responsible to the physician for charges not covered by my insurance agreement. I also understand that if my account becomes delinquent, I will be responsible for any costs of collection of my accounts, including collection fees and attorney costs.

I acknowledge that if my insurance requires a referral, whether it be paper or electronic, that I am responsible for getting an up to date and valid referral. I understand that failure to do so may result in my charges being my responsibility and that payment will be due from me directly.

The information provided by me is true to the best of my knowledge. I authorize release of any previous medical records by fax, mail or phone by either physician or hospital generated. Also, I hereby authorize the doctor or his assistants to the diagnosis and treatment of my condition, to use x-ray examination, or photographs as necessary.

I give Grace Foot And Ankle Center permission to obtain release medical information to insurance companies and referring physicians. I have read the following and understand and agree to Grace Foot And Ankle Center office policy

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.

DATE

SIGNATURE OF PATIENT OR LEGAL GUARDIAN

** If not patient, relationship to patient:

Parent Power of Attorney Legal Guardian Other

Your information will be encrypted.