Patient Registration Form

DATE:

PATIENT NAME: FIRST

MIDDLE INITIAL:

LAST:

DATE OF BIRTH:

AGE:

SOCIAL SECURITY #:

MAILING ADDRESS:

CITY:

STATE:

ZIP:

HOME PHONE #:

CELL #:

E-MAIL -

PRIMARY CARE DOCTOR:

PRIMARY LANGUAGE:

RACE:

PHARMACY:

CITY:

IN CASE OF EMERGENCY:

RELATIONSHIP:

PHONE #:

MARRIED SINGLE WIDOWED DIVORCED OTHER

INSURANCE INFORMATION

PRIMARY INSURANCE COMPANY NAME:

SUBSCRIBER NAME:

DATE OF BIRTH:

EMPLOYER:

MEMBER ID #

GROUP #

RELATIONSHIP TO INSURED:

SECONDARY INSURANCE COMPANY NAME:

SUBSCRIBER NAME:

DATE OF BIRTH:

EMPLOYER:

MEMBER ID #

GROUP #

RELATIONSHIP TO INSURED:

RESPONSIBLE PARTY (If other than patient)

NAME: FIRST

MIDDLE INITIAL:

LAST:

MAILING ADDRESS:

CITY:

STATE:

ZIP:

HOME PHONE:

WORK PHONE #:

DATE OF BIRTH:

SOCIAL SECURITY #:

PATIENT HISTORY

ALLERGIES:

NONE KNOWN

MEDICATION ALLERGIES:

ANESTHESIA ALLERGIES:

FOOD ALLERGIES:

MEDICATION ALLERGIES:

ANESTHESIA ALLERGIES:

FOOD ALLERGIES:

OTHER

PLEASE LIST ALL MEDICATIONS YOU ARE CURRENTLY TAKING (INCLUDING PRESCRIPTIONS, OVER-THE-COUNTER MEDS AND HERBAL SUPPLEMENTS):

HAVE YOU OR ANY OF THE FOLLOWING FAMILY MEMBERS HAD ANY OF THE FOLLOWING CONDITIONS (PLEASE MARK AS FOLLOWS):

MEDICAL HISTORY: FATHER (F) MOTHER (M) SISTER (S) BROTHER (B) PATIENT (P)

ABNORMAL BLEEDING

FATHER (F)

MOTHER (M)

SISTER (S)

BROTHER (B)

PATIENT (P)

ACID REFLUX

FATHER (F)

MOTHER (M)

SISTER (S)

BROTHER (B)

PATIENT (P)

ANEMIA

FATHER (F)

MOTHER (M)

SISTER (S)

BROTHER (B)

PATIENT (P)

ARTHRITIS

FATHER (F)

MOTHER (M)

SISTER (S)

BROTHER (B)

PATIENT (P)

ASTHMA

FATHER (F)

MOTHER (M)

SISTER (S)

BROTHER (B)

PATIENT (P)

BACK TROUBLE

FATHER (F)

MOTHER (M)

SISTER (S)

BROTHER (B)

PATIENT (P)

BLADDER INFECTIONS

FATHER (F)

MOTHER (M)

SISTER (S)

BROTHER (B)

PATIENT (P)

BLOOD CLOTS

FATHER (F)

MOTHER (M)

SISTER (S)

BROTHER (B)

PATIENT (P)

BLOOD TRANSFUSION

FATHER (F)

MOTHER (M)

SISTER (S)

BROTHER (B)

PATIENT (P)

BRONCHITIS/EMPHYSEMA

FATHER (F)

MOTHER (M)

SISTER (S)

BROTHER (B)

PATIENT (P)

CANCER

FATHER (F)

MOTHER (M)

SISTER (S)

BROTHER (B)

PATIENT (P)

DIABETES

FATHER (F)

MOTHER (M)

SISTER (S)

BROTHER (B)

PATIENT (P)

FIBROMYALGIA

FATHER (F)

MOTHER (M)

SISTER (S)

BROTHER (B)

PATIENT (P)

GOUT

FATHER (F)

MOTHER (M)

SISTER (S)

BROTHER (B)

PATIENT (P)

HEART ATTACK

FATHER (F)

MOTHER (M)

SISTER (S)

BROTHER (B)

PATIENT (P)

HEART DISEASE/FAILURE

FATHER (F)

MOTHER (M)

SISTER (S)

BROTHER (B)

PATIENT (P)

HEPATITIS

FATHER (F)

MOTHER (M)

SISTER (S)

BROTHER (B)

PATIENT (P)

HIV/AIDS

FATHER (F)

MOTHER (M)

SISTER (S)

BROTHER (B)

PATIENT (P)

HIGH BLOOD PRESSURE

FATHER (F)

MOTHER (M)

SISTER (S)

BROTHER (B)

PATIENT (P)

KIDNEY DISEASE

FATHER (F)

MOTHER (M)

SISTER (S)

BROTHER (B)

PATIENT (P)

LIVER DISEASE

FATHER (F)

MOTHER (M)

SISTER (S)

BROTHER (B)

PATIENT (P)

LOW BLOOD PRESSURE

FATHER (F)

MOTHER (M)

SISTER (S)

BROTHER (B)

PATIENT (P)

MIGRAINE HEADACHES

FATHER (F)

MOTHER (M)

SISTER (S)

BROTHER (B)

PATIENT (P)

MITRAL VALVE PROLAPSE

FATHER (F)

MOTHER (M)

SISTER (S)

BROTHER (B)

PATIENT (P)

NEUROPATHY

FATHER (F)

MOTHER (M)

SISTER (S)

BROTHER (B)

PATIENT (P)

OPEN SORES

FATHER (F)

MOTHER (M)

SISTER (S)

BROTHER (B)

PATIENT (P)

PNEUMONIA

FATHER (F)

MOTHER (M)

SISTER (S)

BROTHER (B)

PATIENT (P)

POLIO

FATHER (F)

MOTHER (M)

SISTER (S)

BROTHER (B)

PATIENT (P)

RHEUMATIC FEVER

FATHER (F)

MOTHER (M)

SISTER (S)

BROTHER (B)

PATIENT (P)

SKIN DISORDER

FATHER (F)

MOTHER (M)

SISTER (S)

BROTHER (B)

PATIENT (P)

SLEEP APNEA

FATHER (F)

MOTHER (M)

SISTER (S)

BROTHER (B)

PATIENT (P)

STOMACH ULCERS

FATHER (F)

MOTHER (M)

SISTER (S)

BROTHER (B)

PATIENT (P)

STROKE

FATHER (F)

MOTHER (M)

SISTER (S)

BROTHER (B)

PATIENT (P)

THYROID DISEASE

FATHER (F)

MOTHER (M)

SISTER (S)

BROTHER (B)

PATIENT (P)

TUBERCULOSIS

FATHER (F)

MOTHER (M)

SISTER (S)

BROTHER (B)

PATIENT (P)

NONE

FATHER (F)

MOTHER (M)

SISTER (S)

BROTHER (B)

PATIENT (P)

ARE YOU CURRENTLY

PREGNANT NURSING

PLEASE PRINT ALL PRIOR SURGERIES:

ADD TYPE OF SURGERY

SOCIAL HISTORY:

TOBACCO USE:

NEVER FORMER SOMETIME EVERYDAY

OCCUPATION:

WORK ACTIVITY:

WEIGHT:

HEIGHT:

SHOE SIZE:

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

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

Patient Name (please print)

Date

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Parent or Authorized Representative (if applicable) (Please Print)

Patient/Parent Signature

I authorize the following person to have access to my medical records.

Name:

Relationship:

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Patient’s signature:

Hermiston Family Foot Clinic LLC does not leave voice mail messages about your personal health, on your telephone without your permission.

If permission to leave a private voice mail message is given, the message may include information about:

Illness or injury

Treatment

Medications

Appointments

Test results

OFFICE POLICIES

Our office policy requires new patients to pay $185.00 towards your first visit. Once all insurances have paid in full any refund due you will be paid by check and will take two or more billing cycles. This does not apply to Medicare or State Medicaid patients.
Co-pay must be paid at time of service.
If you are more than 10 minutes late for your appointment, you must reschedule.
If you are unable to keep an appointment, please give 24 hours notice. Failure to do so will result in a $60.00 appointment charge. This is not covered by insurance and will be your responsibility. There will be a $25.00 rebilling charge until paid.

AUTHORIZATION/FINANCIAL RESPONSIBILITY

I hereby assign to Donald J. Carlson, D.P.M. all benefits provided by my insurance policy (including Medicare, private insurance and Oregon Health Plans) for medical/surgical care but not exceeded charges stated for such services rendered. I understand that I am responsible for the charges of any medical/surgical services rendered regardless of my insurance coverage. I also understand that I will be responsible for paying within 60 days of date of service. NSF-there will be a $35 charge. I hereby authorize Donald J. Carlson, D.P.M. to release information regarding the patient to the insurance company(s) and/or primary care physician.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Patient/Guardian Signature:

Date

Your information will be encrypted.