REGISTRATION FORMS

Please complete all questions

PATIENT INFORMATION

LAST NAME

FIRST NAME

MIDDLE

DATE

ADDRESS

CITY

STATE

ZIP

MAILING ADDRESS

HOME PHONE

CELL PHONE

SOCIAL SEC. NO.

DATE OF BIRTH

AGE

PATIENT’S EMPLOYER

POSITION

OCCUPATION

E-MAIL

For access to your “Health Vault” an email address is required

PERSONAL PHYSICIAN

DATE LAST SEEN

PREFERRED METHODS OF CONTACT

PHONE

E-MAIL

MAIL

SMS / TEXT

PRIMARY LANGUAGE:

RACE:

WHITE

BLACK

ASIAN

AMER. INDIAN

PACIFIC ISLANDER

NOT SPECIFIED

EMERGENCY CONTACT

NAME

RELATIONSHIP

ADDRESS

HOME PHONE

PERSON RESPONSIBLE FOR BILL

(IF OTHER THAN ABOVE OR IF PATIENT IS A MINOR)

NAME

RELATIONSHIP

ADDRESS

CITY

STATE

ZIP

HOME PHONE

WORK PHONE

INSURANCE INFORMATION

PRIMARY INSUR. CO.

INSURED NAME

INSURED BIRTHDATE

RELATIONSHIP TO PATIENT

ID#

GROUP#

SECONDARY INSUR. CO.

INSURED NAME

INSURED BIRTHDATE

RELATIONSHIP TO PATIENT

AUTHORIZATIONS

I, the undersigned, certify that I (or my dependent) have insurance coverage and assign directly to Medford Foot & Ankle Clinic, PC all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance; and for obtaining any referrals or authorizations if required by my insurance carrier. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.

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.

DATE

Signed

GENERAL HEALTH INFORMATION

Shoe Size

Weight

Height

Most Current Blood Pressure

Are you allergic or sensitive to:

Medication Allergies:

Tape?

Betadine (Iodine)

Latex?

Any problem with local anesthetics?

Any problems taking aspirin or ibuprofen?

Name of your Pharmacy:

List Current Medications and Supplements/Vitamins:

Smoking:

Never Smoked Former Smoker Current Smoker

Frequency:

If Yes, How Long?

List any serious illnesses

List any major surgeries

If yes, for what condition?

Physician treating this condition?

Last date you saw this doctor?

MEDICAL INFORMATION

This Information is Important For Our Records And Your Health

Describe your foot problem

How long has it been bothering you?

Days

Weeks

Years

List any past problems of your feet and ankles

List any past surgical procedures on your feet or ankles

If yes, where?

FAMILY HISTORY

Please list family member (blood relative) that has a history of:

Please select ALL that apply:

CONSENT

I certify that the above information is true & correct to the best of my knowledge. I give permission to the doctor to administer and perform such procedures as may be deemed necessary in the diagnosis and/ or treatment of my condition.

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.