New Patient Forms

Patient Registration Form

This is a confidential record and will be kept in your doctor's office. Information contained on this form will not be released without your permission.

Date:

Name:

Date of Birth:

Age:

Address:

Apartment:

Town/City:

State:

Zip Code:

Home Phone:

Cell Phone:

E-mail:

Primary Doctor:

PCP Phone:

Referred by:

How did you hear about us?

Emergency Contact Information:

Name:

Relationship:

Phone Number:

Patient's Parent/Guardian Information: (if patient is under 18)

Name:

Phone Number:

Demographics:

Preferred Language:

English Spanish Other

If other, specify:

Pharmacy/Prescription Information:

Walgreens

CVS

Wal-Mart

Target

Chubbuck's

Xtra Care

Bernhard's

Freeport Pharm.

Other:

If other, specify:

Address:

Town/City:

State:

Zip Code:

Phone Number:

Are you taking any medications/vitamins?

Yes No

If yes, please list them below:

Are you allergic to any food?

Yes No

Are you allergic to any antibiotics/medicine?

Yes No

If yes, please list them below:

No Known Drug Allergies

Sulfur

Food

Seasonal

Penicillin

Antibiotics

Peanuts

lodine

Other

If Food, please list them below:

If Antibiotics, please list them below:

If Other, please specify:

History of Present IlIness:

Have you ever been to a Podiatrist before:

Yes No

If yes, please list:

Add new row

Please indicate which foot problems you now have:

What discomfort do you have with your feet?

Left

Right

What makes the pain better or worse?

Athletic activities in which you participate (please list and indicate frequency)

Height:

Weight:

Shoe size:

If Diabetes, how long?

If Other, specify:

Please list all hospitalizations and surgeries with dates:

Add new row

Social History:

Do you smoke?

Yes No

Do you consume alcohol?

Yes No

Do you use drugs?

Yes No

If yes, how much daily/weekly and for how long?

Is there a possibility you could be pregnant?

Yes No

Family History:

Foot problems

Heart Disease

Low Blood Pressure

Cancer

High Blood Pressure

Diabetes

Cholesterol

Other:

I have read the above questions and I have answered them to the best of my knowledge. I authorize Long Island Foot Care, P.C./Dr. Emilio Goez, staff, and associates to examine and treat me. I authorize the release of any medical information necessary to process medical insurance claims. In case my health insurance policy does not pay or cover my care expenses, I understand that I am responsible for payment.

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:

Date:

Authorization for Use of Signature on File for Claim Authorization

Date:

Enrollee Name:

Patient Name:

Patient Name

authorize Dr. Emilio A. Goez, Dr. Nicole Castillo, Dr. Marcin Romanczyk. Dr. Anthony Goez to mark the section "ENROLLEE'S OR AUTHORIZED PERSON'S SIGNATURE" with the notation "SIGNATURE ON FILE".

This section authorizes:

The release of any medical information necessary to process claims.
Payment of medical benefits to the undersigned physician or supplier of services described below.

This authorization will remain in force until terminated in writing by the enrollee.

I understand and agree that health and accident policies are an agreement between an insurance carrier and me. In case of denial or termination of benefits, I, the undersigned, understand that I am responsible for payment in full for services rendered.

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/Authorized Signature

Date:

Physician/Podiatrist Signature:

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES (attached to clipboard)

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 so chose) and understood the Notice.

Parent or Authorized Representative

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

Date:

Consent to Obtain Medication History

Patient medication history is a list of prescription medicines that our practice providers, or other providers, have prescribed for you. A variety of sources, including pharmacies and health insurers, contribute to the collection of this history. The collected information is stored in the practice electronic medical record system (EHR/EMR) and becomes part of your personal medical record. Medication history is especially important in helping healthcare providers treat your symptoms and/or illness properly and in avoiding potentially dangerous drug interactions.

It is especially important that you and your provider discuss all your medications in order to ensure that your recorded medication history is 100% accurate. Some pharmacies do not make drug history information available, and your drug history might not include drugs purchased without using your health insurance. Also, over-the-counter drugs, supplements, or herbal remedies that patients take on their own may not be included.

By signing this consent form, you are giving your healthcare provider permission to collect and giving your pharmacy and your health insurer permission to disclose information about your prescriptions that have been filled at any pharmacy or covered by any health insurance plan. This includes prescription medicines to treat AIDS/HIV and medicines used to treat mental health issues such as depression.

I give my permission to allow my healthcare provider to obtain my medication history from my pharmacy, my health plans, and my other healthcare providers.

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

Date:

Email/Text Messaging Consent

We now provide our patients with the option to participate in our online patient communication system. These features include appointment confirmation via email Text Message.

I consent receiving appointment confirmation via:

Please select

Email Text Message

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

Date:

Your information will be encrypted.

New Patient Forms - English

Patient Registration Form

Emergency Contact Information:

Demographics:

Pharmacy/Prescription Information:

History of Present IlIness:

Social History:

Family History:

Authorization for Use of Signature on File for Claim Authorization

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES (attached to clipboard)

Consent to Obtain Medication History

Email/Text Messaging Consent