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Ethnicity:
Preferred Language:
City:
State:
Zip:
Preferred Contact Method:
How were you referred to our clinic?
Emergency Contact Name:
Relation to Patient:
Patient Relationship to Primary Insured:
Medical Insurance:
Secondary Insurance:
Secondary Subscriber Name:
Secondary Subscriber DOB:
Patient Relationship to Secondary Ins. Subscriber:
Self Pay Patients must pay in full at the time of the service. Insurance will be
verified and accepted, however, the co-pay, deductible and/or any non-covered charges
must be paid in full at the time of the visit.
Date of last exam?
By whom?
Which foot is bothering you?
How long have you had the current problem/condition?
List all surgeries and/or hospitalizations you have had:
Check any of the following podiatry conditions you have had:
Check any of the following medical conditions you have had:
Remarks: If any of the above boxes are checked, please explain including date of onset, severity, persistency of symptoms, and your physician currently caring for the problem:
Please Note any family history (Parents, Grandparents, Children, Siblings, Living
or Deceased) for the following:
DISEASE/CONDITION
Yes / No / ?
RELATIONSHIP TO YOU
Please Note history for the following:
DISEASE
IMMUNIZATION DATE
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Disease
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Immunization Date
|
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(This information is kept strictly confidential. However, you may discuss this portion
directly with the doctor if you prefer.)
Smoking Status:
Have you ever been exposed to or infected with:
Do you currently, or have you ever had any problems in the following areas:
Ears, Nose, Mouth, Throat
If you answered Yes to any of the above or have a condition not listed, please explain:
If you answered question (?) to any of the above, please explain:
I, the patient/guardian/responsible party, have accurately and truthfully completed
the information listed on this form. I agree that all fees incurred are my responsibility
regardless of insurance coverage. I acknowledge that I have received a "Notice of
Privacy Practices" regarding the use and disclosure of my health information (Form
is available at front desk or printable from our website).
By clicking "Yes" below you will have electronically signed this form