Town Square Family Foot Care

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New Patient Registration Form

Patient's Full Name

Today's Date

Patient's Street Address

City

State

Zipcode

Birth Date

Gender

Male

Female

Home/Cell Phone

Email Address

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Parent’s name (Legal Representative, for minor):

Family/Primary Physician:

Date last seen:

Did your Family Physician refer you to our clinic?

Yes

If referred by another doctor/provider, whom?

Emergency Contact:

Phone:

Primary Insurance Holders Name:

Date of Birth

Relationship to Patient:

Phone:

We will need to photocopy your insurance card(s)

Your Pharmacy (name and location):

MEDICAL INFORMATION

Why are you seeing the doctor today?

Is this work-related?

Yes

List any medications (including over the counter/supplements) which you currently take

List allergies to medications or tape:

Medical conditions which YOU are currently being treated for: (check all that apply)

Anemia

Diabetes

Liver Disorders

Asthma

Epilepsy

Kidney Disorders

Arthritis

Fainting

Nervous Disorders

Cancer

Heart Problems

Stomach Disorders

Circulatory Problems

High Blood Pressure

Stroke

Other(s):

List any past surgeries you’ve had and year of procedure:

Diseases that run in your immediate family (mother,father):

Are you a current tobacco user (any form of tobacco) :

Yes

Shoe size:

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