NEW PATIENT FORMS

PATIENT INFORMATION

First Name

Middle Name

Last Name

Address:

City:

State:

Zip:

Preferred Gender

Female Male Other

Date of Birth

Shoe Size

Social Security Number

Height

Weight

Upload Your Driver's License

Add file

Please upload a file

Emergency Contact Name

First Name

Last Name

Emergency Contact Phone

Relation

Primary Care Physician Details

Name of Primary Physician

Last time seen by Primary Care Doctor?

Pharmacy

INSURANCE

First Name

Middle Name

Last Name

Policy Holder Name:

DOB (if not self)

Primary Insurance

Do you have Insurance?

Yes No

Upload Insurance (Front)

Add file

Please upload a file

Upload Insurance (Back)

Add file

Please upload a file

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Secondary Insurance

Do you have Secondary Insurance?

Yes No

Upload Insurance (Front)

Add file

Please upload a file

Upload Insurance (Back)

Add file

Please upload a file

Add new row

MEDICAL HISTORY

What is your chief foot/ankle/leg complaint today?

How long has it been bothering you?

If applicable, what was the date of injury?

Work injury?

Yes No

Previous treatments?

How would you describe your pain?

(Please check all that apply)

Sharp

Burning

Shooting

Aching

Throbbing

Pins and Needles

Other

Do you have any other medical conditions?

Do you have current medications?

Yes No

Current Medication

Do you have any allergies?

Yes No

Medications

Food

Latex

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Any other medical issues?

Have you had major events, hospitalizations, surgeries?

Major Events, Hospitalizations, Surgeries

Yes No

Surgical history or any other injuries/trauma (procedure and year)

OTHER HISTORY

Social History

Previous/current: Tobacco use

Yes No

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Alcohol use

Yes No Occasional

Illegal Drug use

Yes No

Type of Work?

Hours of Standing

Type of Flooring at work

Type of Flooring at home

Time spent exercising per week

Family Medical History

Mother

High Blood Pressure

Diabetes

Cancer

Stroke

Father

High Blood Pressure

Diabetes

Cancer

Stroke

Brother

High Blood Pressure

Diabetes

Cancer

Stroke

Sister

High Blood Pressure

Diabetes

Cancer

Stroke

AUTHORIZATION

Financial Policy

Thank-you for choosing Dakota Foot and Ankle Clinic as your healthcare provider. Our goal is to provide quality care in a comfortable atmosphere, in the timeliest manner possible. Please read carefully and sign at the bottom of this page indicating your understanding of these policies. For your convenience, we accept cash, check, Visa, MasterCard, and Discover.

Office Responsibility

An exact fee cannot be determined until the patient has been evaluated and the doctors have reviewed the finding for each date of service. Please understand that there are separate charges for each procedure which may include: office visits, x-rays, injections, casts, braces, and/or any other procedure done within the office or hospital setting (surgeries).
Dakota Foot and Ankle Clinic will bill the patient's insurance company and supply all information needed to accurately process the patient's claim. In addition, Dakota Foot and Ankle Clinic will obtain the patient's copay and deductible information prior to the visit. Copay is due at the time of service as well as 60% of any fees incurred, if the patient's deductible has not been met. If the patient is experiencing financial difficulties, Dakota Foot and Ankle will arrange a payment plan to fit the patient's budget. However, failure to pay a patient balance may result in an inability to schedule future appointments until the balance has been paid in full. Delinquent accounts may be referred to a collection agency.

Patient Responsibility

We believe your time is as valuable as ours. Please arrive on time for your scheduled appointment. If you are more than 15 minutes late, it may be necessary to reschedule your appointment. A 24-hour notice is required for cancellation of appointments. We strive to minimize any wait time. However, emergencies do occur and will take priority over a scheduled visit. We appreciate your understanding.
It is the responsibility of the insured to understand his/her insurance coverage. Patients are responsible for services not covered by their insurance at the time services are rendered, which may include: office visits, co-pays and/or deductibles.

AUTHORIZATION/ASSIGNMENT/RELEASE FORMS

I hereby give my permission to Dakota Foot and Ankle Clinic, P.C.to perform necessary evaluations, administer treatment and to perform such procedures as may be deemed necessary in the diagnosis and/or treatment of my foot condition.

Initials

I acknowledge that I can view a copy of the Notice of Privacy Practices at Dakota Foot Ankle or if I choose; get a copy at Dakota Foot and Ankle clinic's office. And that I have read (or had the opportunity to read if I so choose) and understood the Notice.

Initials

I authorize, to the extent necessary, disclosure of medical information to assist in processing my insurance claim and to communicate with other treating physicians. Furthermore, I assign all payment of medical benefits provided by Health Care Finance Administration (Medicare), my commercial insurance company, or my secondary/supplemental insurance policy for medical/surgical care to Dakota Foot and Ankle Clinic, P.C.

Initials

I consent to receive email/text/voice messages for the confirmation of appointments. I give permission to Dakota Foot & Ankle Clinic and staff to contact my pharmacy and exchange medical information by phone and online.

Yes No

Please list your regular Primary Care Provider or Nurse Practioner and Medical Facility such as Sanford, Mid - Dakota, CHI St. Alexius, etc.

Yes No

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I hereby authorize: Name To release information regarding my medical history, illness or injury, consultation, prescriptions, treatment, diagnosis or prognosis, including x-rays, correspondence and/or medical records including those from my other health care providers that the above named health care provider may hold, by means of mail, fax, or other electronic methods.

Initials

If patient is under the age of 18 this form MUST be signed by parent or guardian.

Signature of patient or Parent/Guardian.

Name of Signer

Date

Office Use Only

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