Patient Information Form

Please correct the errors described below.


  1. I hereby assign my insurance benefits to be paid directly to Council Bluffs Foot & Ankle Care.
  2. I also authorize the physician to release any information requested by my insurance company.
  3. I understand that the above information concerning my condition will be used for filing insurance reports.
  4. I certify all the information to be true and complete.
  5. I have read Council Bluffs Foot & Ankle Care's financial policy and agree with it's terms.
  6. I understand I am financially responsible for all charges not covered by my insurance company.

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.

History Form

List the medications that you are taking (include OTC meds and supplements)

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If yes, please list:

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List your past surgeries:

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Review of Systems

Past Medical History

Family History

If applicable, check which family member has the following conditions:

Social History

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