Patient Information

Date

Legal Name

Last (required)

First Name (required)

Birthdate (required)

Sex (required)

Male Female

Age (required)

Social Security Number

Status (required)

Single Married Widowed Divorced Student

Spouse Name

Primary Language

English

Spanish

Other

Race

White Black/African American Asian Other

Other

Ethnicity

Height

Weight

Current Shoe Size and Width

Length

Width

Patient Address

Street (required)

City (required)

State (required)

Zip (required)

Home Phone (required)

Cell Phone (required)

E-mail Address (required)

How did you hear about our office? If person, who?

Patient Occupation

Employer

Employer Address

Employer Phone

Person Responsible for Payment (If not Patient)

Last

First

Address

Phone

Employer

Employer Address

Employer Phone

Family Physician

Name

Address

City

Date of Last Visit

Primary Insurance

Insurance

Patient's Relationship to Insured

Self Spouse Child Other

Other Specify

Insured’s Name

Insured’s Social Security #

Insured’s Date of Birth

Secondary Insurance

Insurance

Patient's Relationship to Insured

Self Spouse Child Other

Other Specify

Insured’s Name

Insured’s Social Security #

Insured’s Date of Birth

Tertiary Insurance

Insurance

Patient's Relationship to Insured

Self Spouse Child Other

Other Specify

Insured’s Name

Insured’s Social Security #

Insured’s Date of Birth

Local Pharmacy

Name

Address

Mail Order Pharmacy

Name

Contact Person Other than Yourself

Use only in (required)

Emergency Always

Name (required)

Phone Number (home and cell) (required)

Relationship (required)

Previous Footcare

Yes No

If yes, by whom?

Nature and Location of Today's Foot Problem?

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Electronic Signature

Date field

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