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  • New Patient Information Form

    We highly value your privacy and security. All of your information will be encrypted when you click the "Submit" button for secure transmission.
  • Please fill out this form completely.

    At the end of the form there is a "SUBMIT" button that will send it directly to Optima Foot and Ankle. Thank you.
  • Patient Information

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  • Medical Insurance

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  • Health History

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  • List any surgeries you have had in the past with approximate dates.

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  • Social History


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  • Family History




  • Questions specifically for patients with diabetes.

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  • Questions specifically for patients 65 and older.

  • Who should we contact in case of an emergency?

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  • Is there any additional information you would like us to know?

  • We highly value your privacy and security. All of your information will be encrypted when you click the "Submit" button for secure transmission.

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