PATIENT REGISTRATION FORM

Today's Date

Patient Name:

Date of Birth:

Address:

Social Security #:

Home Phone:

Cell Phone:

Consent to TEXT or CALL for Appointment and or Portal updates?

YES NO

Email Address:

Pharmacy:

Primary Care Physician:

Insurance Provider:

ID#

Secondary Insurance Provider:

ID#

In case of Emergency contact

Name:

Relationship to Patient:

Phone#:

The above information is to the best of my knowledge. I authorize my insurance benefits will be paid directly to the Physician(s). I understand that I am financially responsible for any balance remaining. I also authorize New Age Foot & Ankle Surgery L.L.C or insurance company to release any information required to process my claims.

Patient/Legal Guardian

Signature:

DATE:

HEALTH HISTORY QUESTIONNAIRE

Patient Name:

Date of Service:

Patient DOB:

Please choose provider:

Dr. Avery Dr. Khan Dr. Shah

REASON FOR VISIT:

VITALS:

Height:

Weight:

SHOE SIZE:

ALLERGIES:

PATIENT MEDICAL HISTORY:

High Blood Pressure

Diabetes TYPE 1

Diabetes TYPE 2

Cancer

High Cholesterol

Arthritis

Heart Disease

Asthma

MEDICATIONS:

FAMILY MEDICAL HISTORY:

MOTHER:

High Blood Pressure

Diabetes TYPE 1

Diabetes TYPE 2

Cancer

High Cholesterol

Arthritis

Heart Disease

Asthma

FATHER:

High Blood Pressure

Diabetes TYPE 1

Diabetes TYPE 2

Cancer

High Cholesterol

Arthritis

Heart Disease

Asthma

GRANDPARENTS:

High Blood Pressure

Diabetes TYPE 1

Diabetes TYPE 2

Cancer

High Cholesterol

Arthritis

Heart Disease

Asthma

SIBLING(S):

High Blood Pressure

Diabetes TYPE 1

Diabetes TYPE 2

Cancer

High Cholesterol

Arthritis

Heart Disease

Asthma

Smoking Status:

YES NO

If yes, how long?

Alcohol Status:

HEAVY OCCASIONAL MODERATE NONE

SURGICAL HISTORY:

PATIENT REGISTRATION FORM DISCLOSURES & CONSENTS

Patient Name:

Date of Birth:

ASSIGNMENT OF INSURANCE BENEFITS:

I hereby authorize direct payment of my insurance benefits to New Age Foot & Ankle Surgery or the physician for my services rendered to my dependents or me by the physician or under their supervision. I understand that it is my responsibility to know my insurance benefits. I understand and agree that I will be responsible for any co-pay or balance due to New Age Foot & Ankle Surgery.

MEDICARE/MEDICAID/ CHAMPUS INSURANCE BENEFITS:

I certify that the information given by me under these programs is correct. I authorize the release of any of my, or my dependent's records to New Age Foot & Ankle Surgery that these programs may request. I hereby direct that payment of ml or my dependent's authorized benefits be made directly to New Age Foot & Ankle Surgery or the physician on my behalf.

AUTHORIZATION TO RELEASE NON-PUBLIC PERSONAL INFORMATION:

I certify that I have received and read a copy of the New Age Foot & Ankle Surgery Patient InformationPrivacy Policy. I hereby authorize New Age or the physician to release any of my or my dependent's medical or incidental non-public personal information that may be necessary for medical evaluation, treatment, consultation, or processing of insurance benefits.

AUTHORIZATION TO MAIL, CALL OR E-MAIL:

I certify that I understand the privacy risks of mail, phone calls and email. I hereby authorize New Age Foot & Ankle Surgery or physician to mail, call or email me with communications regarding my healthcare. This includes but not limited to appointment reminders, referral arraignments and laboratory results. I understand that I have the right to rescind this authorization at any time by notifying New Age Foot & Ankle Surgery.

LAB/X-RAY/DIAGNOSTIC SERVICES:

I understand that I may receive a separate bill if my medical care includes lab, X-RAY or other diagnostic services. I further understand that I am financially responsible for any co-pay balance due for those services.

CONSENT TO TREATMENT:

I hereby consent to an evaluation, testing and treatment as directed by New Age Foot & Ankle Surgery physician or his designee.

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:

DATE:

GUARANTOR SIGNATURE:

DATE:

GUARANTOR NAME (PRINT):

NAFA Participant

Arrival Screening for COVID-19

Patient Name

DOB:

Date of Service:

Q1 In the last 2 weeks, have you been in contact with someone who was confirmed or suspected to have COVID-19?

Yes No

Q2 Have you traveled outside of VA in the last 2 weeks?

Yes No

Q3 Have you had any Flu/Cold like symptoms in the past 10 days?

Yes No

Q4 Do you or someone you live with have a respiratory illness?

Yes No

1. Do you experience any pain in your legs or feet while at rest?

Yes No

2. Do you have uncomfortable aching, fatigue, tingling, cramping or pain in your feet, calves, buttocks, hip, or thigh during walking/exercising?

Yes No

3. IF yes to question TWO, does the pain go away when you stop walking/exercising?

Yes No

4. IF yes to question TWO, does the pain go away when you stop walking/exercising?

Yes No

5. Do you have an infection, skin wound, or ulcer on your leg or foot that is slow to heal over the past 8-12 weeks?

Yes No

6. Are you over the age of 65?

Yes No

7. Are you over the age of 50?

Yes No

8. Do you have high cholesterol or other lipid (fat) problems or require cholesterol medication?

Yes No

9. Do you have high blood pressure or take medication to reduce blood pressure?

Yes No

10. Do you have diabetes?

Yes No

11. Do you have a history of chronic kidney disease?

Yes No

12. Do you currently or have you ever smoked?

Yes No

13. Do you have history of stroke or mini-stroke (TIA)

Yes No

14. Do you have a history of carotid stenosis, AA (Abdominal aortic aneurysm), and/or stent placement?

Yes No

15. Other:

Yes No

Your information will be encrypted.