Patient Information Form

Patient Name

Date of Birth

Height in Inches

Weight in lbs.

Street Address

City

State

Zip Code

Phone

Phone (alternate)

Emergency Contact

Relationship

Phone

Reason for visit

Primary Doctor

Referring Doctor (if referred from another Doctor)

Preferred Pharmacy Name and Location

Health Insurance Plan

Health Insurance ID

I have no known allergies

Allergies (Medicine/Food)

I consent to receiving text messages

for appointment reminders

from the doctor to discuss care

Other Medical Problems

I have no chronic medical problems

Medications (list all medications that you take)

I take no regular medications

Marital Status

Single Married Divorced Widowed

Occupation

Current Tobacco Use

Yes No

If yes, how many packs/day?

Past Tobacco Use

Yes No

Alcohol Use (if yes, how often?)

Yes No Daily 1-2 times/week 1-2 times/month 1-2 times/year

Type of drink and amount per episode:

List any Surgeries that you have had:

My signature below acknowledges that I was offered the opportunity to view the office's Privacy Policy regarding my medical records (HIPPA) and that I authorize evaluation and treatment by the physician. I also authorize the office to submit claims directly to my insurance company. I also acknowledge that I am responsible for all deductibles and/or copays as per my insurance guidelines.

I also understand that it is my responsibility to obtain any referrals that may be required to see a specialist and that failure to do so may result in rescheduling of my appointment.

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.

Patient Signature

Date

Your information will be encrypted.

Patient Information Form

Linda Lawton, DPM