New Patient Intake Form

Patient First Name

M.I

Patient Last Name

Date of Birth:

Age:

SSN:

Marital status :

Legal sex

Height:

Weight:

Shoe Size:

Do you wish to have access to the patient portal?

Yes No

How do you prefer to receive appointment reminders?

Home address:

City:

State:

Zip:

Phone:

Cell:

Race:

Ethnicity:

E-mail

Primary language spoken:

If referred by a Physician: Provider Name:

If other, specify:

Primary Care Doctor:

Pharmacy:

Location:

Do you have a legal guardian or healthcare power of attorney?

Yes No

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Emergency contact:

Relationship:

Phone #:

Insurance Information:

Primary Insurance Company Name:

Subscriber Name:

Birthdate:

Secondary Insurance Company Name:

Subscriber Name:

Who is responsible for payment?

Relationship to Patient?

Address:

City/State:

Zip:

Phone #:

Is there a family member or other person with whom you would like us to share your medical information?

Yes No

If yes, Name(s):

*Important Information About the Patient Portal: Warnock Foot and Ankle Center utilizes a secure Patient Portal, accessed with your email address, that will allow you to communicate with your provider, view test results, make payments, and view/retrieve your records. We encourage you to activate your portal upon check-in, in order to stay informed and fully participate in your treatment plan.

CONSENTS

The following consents are essential to our ability to treat and serve you, and allow us to provide you quality care. Please read the following items carefully and sign your agreement to each below.

CONSENT TO EXAMINE, DIAGNOSE AND TREAT: I grant permission to Warnock Foot & Ankle Center, and its health care professionals, to examine, diagnose, and recommend treatment that they feel is necessary to resolve the condition noted herein. At times, this treatment may include photography or videography to create a more accurate and complete clinical record.
CONSENT TO ELECTRONIC RECORD SHARING: I grant permission to Warnock Foot & Ankle Center, and its health care professionals, to connect with my other providers electronically, whenever possible, to obtain and share health records for the purposes of continuity of care.
TO RECONCILE MEDICATIONS: I grant Permission to Warnock Foot & Ankle Center, and its health care professionals, to use Pharmacy Benefit Managers to assist in filling in medication gaps, thereby creating a more complete medical history and allowing for more appropriate care.
CONSENT TO COMMUNICATE: I understand that it is important that my provider is able to communicate with me regarding my care. I therefore grant permission to Warnock Foot & Ankle Center, and its health care professionals, to use the contact information I have previously provided to call, text and/or email me to communicate any information related to my treatment. I also understand that Warnock Foot & Ankle Center may leave a message for me, from time to time, but that message will not contain any sensitive clinical information.
CONSENT FOR TRANSFER OF BIOLOGICAL SPECIMEN: Some State statutes prohibit the sale or transfer of a person’s biological specimen from which DNA can be extracted to a third party without the express consent of that person. I understand that during the course of care at Warnock Foot & Ankle Center, it is sometimes necessary to collect and transfer tissue, blood, urine, or other types of biological specimens for testing to aide in diagnosis and treatment. I also understand that in the process of medical procedure or other clinical service, small amounts of biological material may also remain on instruments or other surfaces. I understand that these specimens of biological material, although transferred to third parties for clinical or cleaning purposes, will never be sold by Warnock Foot & Ankle Center, or used for any purpose other than those clinical purposes referenced above. I hereby give my consent for any such biological specimens to be used and/or transferred for the stated, limited, clinical purposes.

By signing here, I signify that I have read and agree with each statement above. I understand that any consent may be revoked, at any time, with the submission of a specific, written revocation.

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ACKNOWLEDGEM ENT OF RECEIPT OF PRIVACY NOTICE

I understand that Warnock Foot & Ankle Center and affiliates may share my health information for treatment, billing, and healthcare operations. I have been provided with a copy of/ or opportunity to review the Notice of Privacy Practices that describes how my health information may be used and shared. I understand that Warnock Foot & Ankle Center and affiliates has the right to change this notice at any time. I may obtain an additional copy of the Notice by contacting the office of my provider.

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PATIENT CLINICAL INFORMATION

ALLERGIES:

Medications:

Tape

Latex

Shellfish

Iodine

Anesthesia

Foods:

Other:

None Known

If Medications, list:

If Foods, list:

If Other, specify:

MEDICATIONS: Please list all medications you are currently taking, and include prescriptions, over the counter products, and supplements:

PRESENT COMPLAINT

1. Please list the foot/ankle problem you are experiencing, and for how long this has been a problem?

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2. Please mark the problem area(s) on the diagram below:

4. Since the time that your problem began, has it

Improved Stayed the same Gotten worse?

5. Have you received treatment for this problem?

Yes No

By a Podiatrist?

Yes No

If yes, by who?

and approximate date of service

6. Was this problem caused by an injury?

Yes No

If yes, was it a work-related injury?

Yes No

If yes, please list the date of injury:

PAST MEDICAL HISTORY / FAMILY HISTORY

1. Have you been diagnosed with Diabetes?

Yes No

2. If yes, what doctor is treating your Diabetes?

Date last seen?

Last A1C result (3 month blood test)?

AIDS/HIV

Patient

Family Member

Anemia

Patient

Family Member

Angina

Patient

Family Member

Arthritis

Patient

Family Member

Artificial heart valve

Patient

Family Member

Artificial joint

Patient

Family Member

Asthma

Patient

Family Member

Back problems

Patient

Family Member

Bleeding disorder

Patient

Family Member

Blood Clots/ DVT

Patient

Family Member

Bronchial problems

Patient

Family Member

Cancer

Patient

Family Member

Chemical dependency

Patient

Family Member

Chest pain

Patient

Family Member

Chronic Pain Syndrome

Patient

Family Member

Circulatory problems

Patient

Family Member

Depression

Patient

Family Member

Diabetes

Patient

Family Member

Emphysema

Patient

Family Member

Epilepsy

Patient

Family Member

Eye problems

Patient

Family Member

Fainting

Patient

Family Member

Fibromyalgia

Patient

Family Member

Foot and leg cramps

Patient

Family Member

Gout

Patient

Family Member

Heart Disease

Patient

Family Member

Hemophilia

Patient

Family Member

Hepatitis or jaundice

Patient

Family Member

High blood pressure

Patient

Family Member

High Cholesterol

Patient

Family Member

Hypothyroidism

Patient

Family Member

Kidney problems

Patient

Family Member

Liver Disease

Patient

Family Member

MRSA

Patient

Family Member

Phlebitis

Patient

Family Member

Radiation therapy

Patient

Family Member

Respiratory Disease

Patient

Family Member

Rheumatoid arthritis

Patient

Family Member

Shortness of breath

Patient

Family Member

Special diet

Patient

Family Member

Stroke

Patient

Family Member

Swelling in ankles and feet

Patient

Family Member

Tuberculosis

Patient

Family Member

Ulcers

Patient

Family Member

Varicose veins

Patient

Family Member

SOCIAL HISTORY

2. Do others depend on you for their care?

Children

Pet(s)

Elderly or disabled family member

Other

If Children, ages:

If Pet(s), what kind?

If Elderly or disabled family member, specify:

If Other, specify:

If quit, specify:

If Smoke, packs/day

For:

What kinds of exercise

SURGICAL HISTORY

1. Please list all prior major surgeries (Type of Surgery, Date):

2. Please list all Hospitalizations other than for surgery (Reason for hospitalization, Date):

3. Have you ever had a reaction or complication from surgical anesthesia?

Yes No

If yes, please provide details:

SOCIAL DETERMINANTS OF HEALTH:

As we aim to provide the best care we can, it is helpful for us to know some personal information about you. The following questions are completely optional. Based on this information, we might be able to connect you to additional care services or benefit options.

FINANCIAL POLICY

Insurance We participate in most insurance plans, including Medicare. If you are not insured by a plan, we do business with, or do not have medical insurance (self-pay) payment in full is expected at each visit. If you are insured by a plan, we do business with but do not have an up-to-date insurance card, payment in full for each visit is required until we can verify your coverage. We require a current copy of your driver’s license/photo ID and insurance card (if applicable) to be seen by our provider. We will capture copies of this identification to store in your patient chart as proof of insurance. It is your responsibility to update us when your coverage changes. If you have questions about whether we participate with your plan, please contact your insurer.
Copay/Coinsurance/Deductible: Copays, Coinsurances and Deductibles are determined by your insurer and are due at the time of service. In addition, some services are considered as “non-covered” by your insurer. These services are your responsibility and are also due at the time of service. before receiving care from one of our providers. It is your responsibility to acquire these documents before the date of service, and if the referral/authorization is not presented at the time of service, you will be financially responsible for the entire cost of the visit.
Claim Submission As a courtesy, we will submit your claim on your behalf, and our teams will assist in getting your claim paid. At times, your insurance company may need you to supply certain information to them directly. It is your responsibility to comply with their request, and failure to comply with these requests may result in denied claims, the balance of which will be assigned to your responsibility.
Patient Billing We will send up to three (3) notices to you for balances due. After three notices with non-payment, you may be subject to further collection efforts. All account balances and past due accounts must be settled before seeing our providers. If you have difficulty paying your balance, please speak to our team. Payment arrangements may be made on a case-by-case basis.
No Show If you are unable to keep a scheduled appointment, please notify our office at least 24 hours in advance. Failure to notify will result in a $25 no show fee. This fee is not covered by insurance and will be the sole responsibility of the patient. After three (3) No Show appointments, you will be subject to termination from the practice.
Returned Checks In the event that your check is returned for insufficient funds, you will be assessed a charge of $25.00. Multiple returned checks or submission of fraudulent checks will result in termination from the practice.

I have read the above policy regarding my financial responsibility to Warnock Foot & Ankle Center for services provided. I agree to pay Warnock Foot & Ankle Center any balance unpaid by my insurance carrier for myself or my dependent as stipulated below.

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ASSIGNMENT OF BENEFITS

I, the undersigned, certify that I (or my dependent) have coverage with my insurance as presented, and assign directly to Warnock Foot & Ankle Center all insurance benefits, payable to me for services rendered. I understand that I am responsible for payment of deductibles, copayments, coinsurances and/or non-covered services. I hereby authorize the doctor to release all information necessary to secure payment of benefits. I authorize RELEASE OF MEDICAL INFORMATION to my insurance carrier or requested physician to provide continuity of care. I authorize the use and representation of this signature on all insurance submissions.

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