Foot and Ankle Center of Frisco/Little Elm Patient Forms

Consent for Treatment:
I, First Name* Last Name* , hereby give my consent for medical treatment by the physician(s) of the Foot and Ankle Center of Frisco/Little Elm to myself or my dependent. I may revoke consent at any time in writing. I certify that all information provided to Foot and Ankle Center of Frisco/Little Elm is correct.
Printed Patient/Parent or Guardian Name*
Patient/Parent or Guardian Signature*

Clear
Today's Date:*

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Date
Request for Confidential Communication:
Do you authorize Foot and Ankle Centers of Frisco/Little Elm to leave you detailed voice messages regarding your medical condition?*

YesNo
Patient/Parent or Guardian Signature*

Clear
Today's Date:*

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Date
Additionally, keeping our patient's information private is very important to us, and, by default, we will only disclose information related to the patient's billing account and medical conditions to the patient or legal guardian.
If you would like to provide an additional contact (other than the patient or legal guardian) that Foot and Ankle Center of Frisco/Little Elm can disclose this information, please complete the field below. Please choose the person you would like our office to list as your Emergency Contact in the event an emergency was to take place.
Please print the person's name, relationship to the patient, and phone number.
Use of Electronic Communication from Foot and Ankle Center of Frisco/Little Elm to Patient:
Foot and Ankle Center of Frisco/Little Elm offers you a convenience to communicate electronically with you under the terms and conditions outlined below. If using your work email, please consider the privacy implications that your employer may have the right and/or ability to review all emails received at your work address.
Do you authorize the Foot and Ankle Centers of Frisco/Little Elm to communicate with me electronically via email?*

YesNo
TERMS AND CONDITIONS:

(1.) The patient is responsible to notify Foot and Ankle Centers of Frisco/Little Elm promptly of any changes to his/her email address.

(2.) All electronic communications are considered a part of your medical record and are recorded. Those who have access to your medical record also have access to the email messages sent to you.

(3.) Foot and Ankle Centers of Frisco/Little Elm will not share your email address with anyone unauthorized to view your medical record. You have the right to revoke authorization in writing at any time.
Patient/Parent or Guardian Signature*

Clear
Today's Date:*

MonthDayYear
Date
Patient Photograph Consent and Release Form:
I hereby acknowledge that I have been advised that photographs will be taken care of my feet. The photographs will be taken by one of the members of the Foot and Ankle Centers of Frisco/Little Elm medical staff. Any photographs taken will become part of my medical records. My photographs are to be used for the purposes or insurance pre-authorization, office and hospital medical charts, progress, and any necessary medical treatment.
Patient/Parent or Guardian Signature*

Clear
Today's Date:*

MonthDayYear
Date
***OPTIONAL*** Do you authorize that your photographs be used for the purposes of medical seminars, website publication and/or office photo albums? All efforts will be made to ensure patient anonymity and confidentiality. No names or identifying references will be made in conjunction with published photography.*

YesNo

COVID-19 SCREENING:
Please type patient's name and date of birth below: *
Have you, or any members in your household, traveled outside of Texas within the last 2-3 weeks?*

YesNo
Have you been in contact with any person diagnosed (laboratory confirmed) with COVID-19?*

YesNo
Are you experiencing severe acute lower respiratory illness (cough, shortness of breath) or fever?*

YesNo
I attest that the information above is both accurate and honest.
Patient/Parent or Guardian Signature*

Clear
Today's Date:*

MonthDayYear
Date
This is a fill in the blanks field. Please add appropriate blank fields and text.
Should be Empty:

Foot and Ankle Center of Frisco/Little Elm

Contact Information:

Insurance Information:

Past Medical History:

Social History:

Family History (Blood Relatives):

Primary Concern/Previous Treatments:

Consent for Treatment:

Request for Confidential Communication:

Use of Electronic Communication from Foot and Ankle Center of Frisco/Little Elm to Patient:

Patient Photograph Consent and Release Form:

Medical Records Release Form:

COVID-19 SCREENING: