OAKDALE, PA
101 DIXIE DRIVE OAKDALE, PA 15071 | PHONE #: 412-787-8380 | FAX #: 414-787-1099
I AUTHORIZE THE PRACTICE TO SPEAK WITH THE FOLLOWING PEOPLE IN REGARDS TO MY DIAGNOSIS AND/OR TREATMENT OPTIONS OR ANY OTHER RELATED HEALTHCARE ISSUES:
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.
THIS INFORMATION MUST BE COMPLETED IF THE POLICYHOLDER IS NOT THE PATIENT
SECONDARY INSURANCE COMPANY NAME:
FINANCIAL RESPONSIBILITY: EXAMPLE MINOR CHILD OF SEPARATED PARENTS
ALLERGIES:
FAMILY HISTORY:
DO YOU HAVE A FAMILY HISTORY OF & WRITE WHO(PARENTS, MATERNAL/PATERNAL GRANDPARENTS)
SOCIAL HISTORY:
SURGERIES:
CURRENT PROBLEMS
JEFFREY T. MOLINARO, DPM, FACFAS
PATIENT CONSENT FOR TREATMENT FORM
TO THE BEST OF MY KNOWLEDGE, I HAVE ANSWERED THE QUESTIONS ON THIS FORM ACCURATELY. I UNDERSTAND THAT PROVIDING INCORRECT INFORMATION CAN BE DANGEROUS TO MY HEALTH. I UNDERSTAND THAT IT IS MY RESPONSIBILITY TO INFORM THE DOCTOR AND OFFICE STAFF OF ANY CHANGES IN MY MEDICAL STATUS. I HEREBY CONSENT AND GIVE MY PERMISSION TO THE DOCTOR (AND THE DOCTORS ASSISTANCE OR DESIGNATED REPLACEMENT)TO ADMINISTER AND PERFORM SUCH PROCEDURES UPON ME AS THE DOCTOR DEEMS NECESSARY.
NOTICE OF PRIVACY PRACTICES
I HAVE SEEN A COPY OF THE NOTICE OF PRIVACY PRACTICES FROM JEFFREY T. MOLINARO, DPM, FACFAS ON THE WEBSITE OR IN THE OFFICE.
PATIENT FINANCIAL POLICY
BY SIGNING, I AGREE TO THE FOLLOWING FINANCIAL STATEMENTS AND YOUR UNDERSTANDING OF OUR FINANCIAL POLICIES IS AN ESSENTIAL ELEMENT OF YOUR CARE AND TREATMENT. IF YOU HAVE ANY QUESTIONS, PLEASE DISCUSS THEM WITH OUR OFFICE STAFF.
I HAVE READ AND UNDERSTOOD THIS INFORMATION. I AM THE PATIENT OR I AM AUTHORIZED TO ACT ON BEHALF OFTHE PATIENT TO SIGN THIS DOCUMENT, VERIFYING CONSENT TO THE ABOVE STATED TERMS.
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