NEW PATIENT FORM

1250 YOUNGSTOWN WARREN ROAD UNIT 1A NILES, OH 44446 | PHONE #: 330 -544-4141 | FAX #: 330-544-4134

JEFFREY T. MOLINARO, DPM, FACFAS JEFFREYMOLINARODPM.COM

PATIENT INFORMATION

Date

LAST NAME:

FIRST NAME:

MIDDLE INITIAL:

DATE OF BIRTH:

AGE:

SS#

SEX:

M F

ADDRESS:

CITY/STATE:

ZIP:

HOME PHONE #:

CELL PHONE #:

E-MAIL:

EMPLOYER/SCHOOL:

OCCUPATION:

EMPLOYER ADDRESS:

EMPLOYER #:

EMERGENCY CONTACT:

RELATIONSHIP:

PHONE #:

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.

NAME:

RELATIONSHIP:

PHONE:

NAME:

RELATIONSHIP:

PHONE:

INSURANCE INFORMATION

PRIMARY INSURANCE COMPANY NAME:

MEMBER ID #:

GROUP #:

THIS INFORMATION MUST BE COMPLETED IF THE POLICYHOLDER IS NOT THE PATIENT

POLICY HOLDER NAME:

DATE OF BIRTH:

SS #:

RELATIONSHIP TO PATIENT?

PHONE #:

ADDRESS:

CITY/STATE:

ZIP:

EMPLOYER:

EMPLOYER ADDRESS:

EMPLOYER #:

SECONDARY INSURANCE COMPANY NAME:

SECONDARY INSURANCE COMPANY NAME:

MEMBER ID #:

GROUP #:

THIS INFORMATION MUST BE COMPLETED IF THE POLICYHOLDER IS NOT THE PATIENT

POLICY HOLDER NAME:

DATE OF BIRTH:

SS #:

RELATIONSHIP TO PATIENT?

PHONE #:

ADDRESS:

CITY/STATE:

ZIP:

EMPLOYER:

EMPLOYER ADDRESS:

EMPLOYER #:

FINANCIAL RESPONSIBILITY: EXAMPLE MINOR CHILD OF SEPARATED PARENTS

NAME:

RELATIONSHIP TO PATIENT?

DOB:

SS#:

PHONE #:

ADDRESS:

CITY/STATE:

ZIP:

EMPLOYER:

EMPLOYER #:

EMPLOYER ADDRESS:

YOUR MEDICAL HISTORY

HEIGHT:

WEIGHT:

SHOE SIZE:

PRIMARY CARE DOCTOR:

PHONE #:

LOCAL PHARMACY:

LOCATION:

PHONE #:

PLEASE LIST ALL MEDICATIONS YOU ARE CURRENTLY TAKING (NAME-DOSAGE- HOW OFTEN DO YOU TAKE?)

IF HEPATITIS: Please choose

A B C

IF DIABETES: Please choose

PILL INSULIN

ALLERGIES:

FOODS

MEDICATIONS

OTHER

FAMILY HISTORY:

DO YOU HAVE A FAMILY HISTORY OF & WRITE WHO(PARENTS, MATERNAL/PATERNAL GRANDPARENTS)

ADOPTED

DIABETES: TYPE 1 OR TYPE 2

CANCER

HIGH BLOOD PRESSURE

STROKE

CORONARY ARTERY DISEASE

ARTHRITIS

HEART DISEASE

THYROID DISEASE

OTHER

SOCIAL HISTORY:

USE OF TOBACCO

NEVER QUIT SMOKE

IF QUIT, HOW LONG AGO?

IF SMOKE, PACKS/DAY

USE OF ALCOHOL

NEVER RARE OCCASIONAL DAILY

IF DAILY, TYPE

SURGERIES:

TYPE OF SURGERY

CURRENT PROBLEMS

ANKLE OR FOOT PAIN

Yes No

ATHLETE’S FOOT

Yes No

BUNIONS

Yes No

CORNS/CALLUSES

Yes No

FLAT FEET

Yes No

FOOT OR LEG CRAMPS

Yes No

HEEL PAIN

Yes No

INGROWN TOENAILS

Yes No

NUMBNESS

Yes No

PLANTAR WARTS

Yes No

TIRED FEET

Yes No

SWELLING IN ANKLES/ FEET

Yes No

Image

WHAT SPECIFIC PROBLEM BRINGS YOU TO OUR OFFICE TODAY? LEFT OR RIGHT FOOT

IS YOUR PROBLEM ON THE TOP/ BOTTOM/ INSIDE/ OUTSIDE OF WHICH FOOT?

HOW LONG AGO DID THIS PROBLEM FIRST START? DAYS / WEEKS / MONTHS / YEARS

DID YOUR PAIN OR PROBLEM:

BEGIN ALL OF A SUDDEN GRADUALLY DEVELOP OVER TIME

HOW WOULD YOU DESCRIBE YOUR PAIN?

NO PAIN

SHARP

DULL

ACHING

BURNING

RADIATING

ITCHING

STABBING

WAS THIS PROBLEM CAUSED BY AN INJURY?

NO YES

IF YES, DESCRIBE

IF YES, WAS IT A WORK-RELATED INJURY?

NO YES

HOW MUCH ARE YOU ON YOUR FEET AT WORK?

10% 25% 50% 75% 100%

WHO REFERRED YOU TO THE OFFICE?

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.

SIGNATURE

Date

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.

(INITIAL)

PATIENT FINANCIAL POLICY

AS OUR PATIENT, YOU ARE RESPONSIBLE FOR ALL AUTHORIZATIONS/REFERRALS NEEDED TO SEEK TREATMENT IN THIS OFFICE.
UNLESS OTHER ARRANGEMENTS HAVE BEEN MADE IN ADVANCE BY YOU, OR YOUR HEALTH INSURANCE CARRIER,PAYMENT FOR OFFICE SERVICES ARE DUE AT THE TIME OF SERVICE. WE WILL ACCEPT VISA, MASTERCARD, DISCOVER,CASH OR CHECK.
YOUR INSURANCE POLICY IS A CONTRACT BETWEEN YOU AND YOUR INSURANCE COMPANY. AS A COURTESY, WE WILL FILE YOUR INSURANCE CLAIM FOR YOU IF YOU ASSIGN THE BENEFITS TO THE DOCTOR. IN OTHER WORDS, YOU AGREE TOHAVE YOUR INSURANCE COMPANY PAY THE DOCTOR DIRECTLY. IF YOUR INSURANCE COMPANY DOES NOT PAY THE PRACTICE WITHIN A REASONABLE PERIOD, WE WILL HAVE TO LOOK TO YOU FOR PAYMENT.
WE HAVE MADE PRIOR ARRANGEMENTS WITH CERTAIN INSURERS AND OTHER HEALTH PLANS TO ACCEPT AN ASSIGNMENT OF BENEFITS. WE WILL BILL THOSE PLANS WITH WHICH WE HAVE AN AGREEMENT AND WILL ONLY REQUIRE YOU TO PAY THE COPAY/COINSURANCE/DEDUCTIBLE.
IF YOU HAVE INSURANCE COVERAGE WITH A PLAN WITH WHICH WE DO NOT HAVE A PRIOR AGREEMENT, WE WILL PREPARE AND SEND THE CLAIM FOR YOU ON AN UNASSIGNED BASIS. THIS MEANS YOUR INSURER WILL SEND THE PAYMENT DIRECTLY TO YOU. THEREFORE, ALL CHARGES FOR YOUR CARE AND TREATMENT ARE DUE AT THE TIME OF SERVICE.
ALL HEALTH PLANS ARE NOT THE SAME AND DO NOT COVER THE SAME SERVICES. IN THE EVENT YOUR HEALTH PLAN DETERMINES A SERVICE TO BE "NOT COVERED," OR YOU DO NOT HAVE AN AUTHORIZATION, YOU WILL BE RESPONSIBLE FOR THE COMPLETE CHARGE. WE WILL ATTEMPT TO VERIFY BENEFITS FOR SOME SPECIALIZED SERVICES OR REFERRALS;HOWEVER, YOU REMAIN RESPONSIBLE FOR CHARGES TO ANY SERVICE RENDERED. PATIENTS ARE ENCOURAGED TO CONTACT THEIR PLANS FOR CLARIFICATION OF BENEFITS PRIOR TO SERVICES RENDERED.
YOU MUST INFORM THE OFFICE OF ALL INSURANCE CHANGES AND AUTHORIZATION/REFERRAL REQUIREMENTS. IN THE EVENT THE OFFICE IS NOT INFORMED, YOU WILL BE RESPONSIBLE FOR ANY CHARGES DENIED.-FOR MOST SERVICES PROVIDED IN THE HOSPITAL, WE WILL BILL YOUR HEALTH PLAN. ANY BALANCE DUE IS YOUR RESPONSIBILITY.
PAST DUE ACCOUNTS ARE SUBJECT TO COLLECTION PROCEEDINGS. ALL COSTS INCURRED INCLUDING, BUT NOT LIMITED TO, COLLECTION FEES, ATTORNEY FEES AND COURT FEES SHALL BE YOUR RESPONSIBILITY IN ADDITION TO THE BALANCEDUE TO THIS OFFICE.
THERE IS A SERVICE FEE OF $35.00 FOR ALL RETURNED CHECKS. YOUR INSURANCE COMPANY DOES NOT COVER THIS FEE.

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.

(INITIAL)

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.

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 SIGNATURE

( IF OTHER THAN THE PATIENT STATE THE RELATIONSHIP TO PATIENT)

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.

SIGNATURE OF WITNESS

Date

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