FOOT CARE SPECIALISTS, PLLC

Personal Information

Name

Address

City

State

Home Phone #

Cell Phone #

Date of Birth

Social Security #

Age

Sex

M F

Height

Weight

Shoe Size

Marital Status

Email address

Referred By

Patient’s Employer

Phone #

Occupation

Policy Holder’s Name

Policy Holder’s Date of Birth

Emergency Contact

Relationship to Patient

Address

Phone #

Insurance Information

Primary (1st) Insurance Information

Insurance Name:

Insurance ID:

Insurance Policy Group:

Who is Primary on the Account?

Name:

Relationship to Insured

Spouse Child

Other:

Sex

Male Female

Address:

City:

State:

Zip:

Phone Number:

Birthday:

Employer/School:

Secondary (2nd) Insurance Information

Insurance Name:

Insurance ID:

Insurance Policy Group:

Who is Primary on the Account?

Name:

Relationship to Insured

Spouse Child

Other:

Sex

Male Female

Address:

City:

State:

Zip:

Phone Number:

Birthday:

Employer/School:

Tertiary (3rd) Insurance Information

Insurance Name:

Insurance ID:

Insurance Policy Group:

Who is Primary on the Account?

Name:

Relationship to Insured

Spouse Child

Other:

Sex

Male Female

Address:

City:

State:

Zip:

Phone Number:

Birthday:

Employer/School:

No Insurance/Self Pay

Yes

Financially Responsible Person if not Patient

Last Name

First Name

Gender

F M

Birth Date

Street Address

City

State

Zip

Home Phone #

Cell Phone #

Primary Care Physician

Pharmacy Name

Primary Problem

How long have you had this problem?

Have you ever been treated for this problem, IF yes, explain?

Could you be pregnant?

Yes No

Are you a smoker?

Do you have a history of smoking?

How many packs a day?

Do you consume Alcoholic Beverages?

Drinks per day/or per week?

Medical Information

Family History

Are your parents still living?

Yes No

If NO, what was the cause of death?

Please check the following health condition associated with mom, dad, grandparents.

Disease

Relationship

Alzheimer’s Disease

Aneurysm

Arthritis

Asthma

Cancer

Congestive Heart Failure

COPD

Dementia

Diabetes

DVT ( Blood Clot)

Emphysems

Foot Deformities

GERD (Heart Burn)

Heart Disease

Hepatitis

Hypercholesterolemia

Hypertension (High Blood Pressure)

Hyperthyroidism

Hypothyroidism

Kidney Disease

Lung Disease

Lupus

Migraines

Myocardial Infarction(MI-Heart Attack)

Parkinson’s Disease

Pneumonia

PVD (Peripheral Vascular Disease)

Renal Failure

Stomach Ulcer

Stroke

Tumor

Toenail Problems

Tuberculosis

Unknown

Unknown of Family History

I certify to the best of my knowledge that all of the information above is correct.

I understand that I am financially responsible for all chargers not pain by insurances (such as deductibles, non-covered services, co-pays, co-insurances). I hereby aurthorize the doctor to release all information necessary to secure all insurance benefits and hereby assign all insurance benefits to Foot Care Specialists, PLLC. I authorize the use of this signature on all insurance submissions. This signature gives my permission for treatment by Dr. LaWanda Bailey-Rayner.

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

Date

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