Intake Form

Please complete all required fields!

Please complete the following form and answer all questions before arriving for your appointment.

Be sure to include your insurance information.
We'll see you soon!

Patient Information

First name (*)

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Middle Initial

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Last name (*)

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Your Email Address (Responsible Party) (*)

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Mailing Address (*)

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City (*)

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State (*)

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Zip-Code (*)

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Phone number (*)

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Date of Birth: Month (*)

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Day (*)

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Year (*)

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Sex (*)

Male Female

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Marital Status (*)

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*This information is requested due to Healthcare Reform laws dictated by Congress.

Ethnicity

Hispanic or Latino Non-Hispanic or Non-Latino Decline to Specify

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Preferred Language(*)

English Spanish Other

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Specify

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Are you pregnant?(*)

No Yes

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Are you nursing?(*)

No Yes

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Have you completed an Advance Directive (living will)? (*)

Yes No

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Primary Care Physician (*)

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Primary Care Physician Address (*)

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Physician Phone Number (*)

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Date last seen: Month

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Day

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Year

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Pharmacy (*)

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Pharmacy Phone (*)

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Who?

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Other

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Primary Reason for Visit (*)

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Duration of Condition (*)

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What helps / makes it worse?

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Is it limiting your activity level? (*)

Yes No

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Secondary problem (if there is one)

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Please list any drug allergies (*)

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List Medications You Take (*)

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Specify other

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If you have cancer, please list type and treatment

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Please list past surgeries and year surgery was performed (*)

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Is your problem related to a Workman’s Comp injury or an auto/other accident?(*)

No Yes

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Do you smoke, vape or use chewing tobacco?(*)

Never Past Yes

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Please specify

Cigarettes Cigars Chewing Tobacco Vaping

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How many per day?

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Method of Quitting

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Do you have/have had a recreational use problem?(*)

Never Past Yes

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Please specify

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Do you drive?(*)

Never Past Yes

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Do you have children?(*)

No Yes

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Are you currently pregnant?(*)

Never Past Yes

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Family History

Which family members had the below medical conditions? (father, mother, sibling, etc.)

Diabetes

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Stroke

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Cancer

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Arthritis

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Heart Attack

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Hypertension/High Blood Pressure

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Asthma

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Heart Disease

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High Cholesterol

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Liver Disease

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Mental Illness

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Lung Disease

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Kidney Disease

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Vascular Disease

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Insurance Information

Subscriber's Name (*)

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Patient's Relation to the Subscriber (*)

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Subscriber's Date of Birth: Month (*)

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Day (*)

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Year (*)

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HMO (*)

Yes No

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Primary Insurance (*)

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Policy Number (*)

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Policy Holder Name (*)

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Policy Holder Date of Birth: Month (*)

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Day (*)

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Year (*)

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Secondary Insurance

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Secondary Policy Number

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Occupation (*)

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Employer (*)

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Employer Address

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City

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State

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Zip-Code

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Employer Phone Number

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Emergency Contact

First Name (*)

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Last Name (*)

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Relationship to Patient (*)

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Phone (*)

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Responsible Party (if minor patient)

First Name

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Last Name

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Relationship to Patient

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Date of Birth: Month

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Day

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Year

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View Privacy Policy

Authorization to Release Information and Pay Insurance Benefits

I hereby authorize The Podiatry Center, PC to render medical services to myself (or my child). I authorize the release any information regarding medical history, diagnosis and treatment to my insurance company regarding the claim. Also, by my signature and copies thereof, I authorize payment directly to The Podiatry Center, PC of benefits otherwise payable to me. It is understood that services and supplies may not be covered by my insurance, and I agree to pay for these services or supplies rendered. I understand that in the event my account is turned over to an attorney or collection agency, I will be responsible for fees in the amount of 33% plus interest of any unpaid balance and court costs involved.

To our Medicare Patients: I request that payment of authorized Medicare benefits be made on behalf of The Podiatry Center, PC for services furnished to me. I authorize any holder of medical information about me to be released to the health care administration (and its agents) any information needed to determine these benefits or the benefits payable for related services.

Signature: (*)

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I consent to the use of disclosure of my protected health information by The Podiatry Center, PC’s practice for the purpose of diagnosing or providing treatment to me, obtaining payment for my health care bills, or to conduct health care operations of The Podiatry Center, PC’s practice. I understand that diagnosis or treatment of me by the physicians at The Podiatry Center, PC may be conditioned upon my consent as evidenced by my signature of this document.

I consent to the use of photography that may be part of the procedure for medical purposes.

I understand I have the right to request restrictions as to how my protected health information is used or disclosed to carry out treatment, payment or healthcare operations of the practice. The Podiatry Center, PC’s practice is not required to agree to the restrictions that I may request. However, if the Podiatry Center, PC agrees to a restriction that I request, the restriction is binding on The Podiatry Center, PC’s practice.

I have the right to revoke this consent in writing at any time, except to the extent of The Podiatry Center, PC’s practice has taken action in reliance on this consent.

My protected health information means health information, including my demographic information, collected from me and created or received by my physician, another health care plan/provider, my employer or a health care clearinghouse. This protected information relates to my past, present, or future physical/mental health or condition and identifies me, or there is a reasonable basis to believe the information may identify me.

I understand that I have a right to review the Notice of Privacy Practice prior to signing this document. The Notice of Privacy Practice describes the types of uses and disclosures of my protected health information that will occur in my treatment, payment of bills or performance of healthcare operations of this practice.

The Podiatry Center, PC reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised notice of these practices by calling the office and requesting a copy be sent in the mail.

Disclosure of Information

I DO I DO NOT

give permission to Podiatry Center, PC, to leave information on my answering machine and/or with my family members regarding treatment plans, referrals, test results and/or billing and payment information. Invalid Input

Disclosures may be made to family and/or friends related to the patient’s health or as needed for payment of health care services rendered. We will only disclose information relevant to current treatment.

By signing the statement, you agree that we may disclose information to the person(s) listed below in person or by phone.

Name

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Relationship

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Phone Number

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Name

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Relationship

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Phone Number

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Insurance/Referral Policy

Please check with your insurance to confirm that The Podiatry Center, PC and their physicians participate with your plan. You will be responsible for any Co-insurance, Co-pays or Deductibles required by your insurance. Fees will be collected at the time of visit. You will be responsible to obtain a referral. Please understand that we will not be able to see you without a proper referral at the time of service. If a referral is not received, you will be responsible for any cost incurred from your visit.

Non-Participating Insurance: If we are not in network with your health insurance provider, you will be responsible for payment in full at the time of service.

No Show Policy: The Podiatry Center, PC will charge a $25 no show fee for appointments not cancelled within 24 hours.

Paperwork Policy: A $25 fee will be charged for forms such as disability paperwork, work forms and personal insurances that are not part of our regular billing paperwork. Payment is required at the time of completion.

Copays: All copays are due at the time of service and collected prior to being treated by the physician.

Surgery Policy: If surgery is deemed necessary and scheduled, a non-refundable deposit of $200 will be collected to reserve your surgical time and will be put towards the fees associated with your procedure. In addition, a $100 fee will be charged for surgeries canceled within one week of the scheduled surgery date.

Signature: (*)

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Intake Form

Patient Information

Social History

Family History

Insurance Information

Emergency Contact

Responsible Party (if minor patient)

Authorization to Release Information and Pay Insurance Benefits

Consent for Treatment

Disclosure of Information