Town Square Family Foot Care

Today's Date:

Patient's First Name:

MI:

Last Name:

Patient’s Date of Birth:

Preferred Name/Nickname:

Gender:

Home/Cell Phone

Patient's Street Address:

City:

State:

Zip:

E-mail address

From time to time we communicate with patients by Email and Text messages for appointment reminders and messages. You may opt out of these messages at any time.

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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 No

If referred by another doctor/provider, whom?

How did you hear about our clinic?

Emergency Contact:

Phone:

➤ We will need to photocopy your insurance card(s)

Please upload your file(s) here

Add file

Please upload a file

Primary Insurance Holder’s Name:

Date of birth:

Relationship to patient:

Phone:

Your Pharmacy's Name:

Your Pharmacy's Location:

Shoe size:

Width:

Are you a current tobacco user:

Yes No

Patient’s Name:

Date of birth:

Why are you seeing the doctor today?

Is this work-related?

Yes No

If Heart, please specify:

If Kidney, please specify:

If Cancer, please specify:

If Stomach, please specify:

If Circulatory, please specify:

If Thyroid, please specify:

If Liver, please specify:

If Nervous disorders, please specify:

If Other(s), please specify:

Current Medications:

List all medications you are presently taking including all prescriptions, over-the counters, herbals and vitamin/mineral/dietary (nutritional) supplements with each medication’s name, dosage, frequency and administered route (oral, sublingual, subcutaneous injections, and/or topical):

Add current medication

List allergies to medications or tape:

Add allergy

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

Add surgery

List the medical conditions of your mother and father:

Mother:

Father:

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