• Foot and Ankle Center of Frisco/Little Elm

    Patient Information
  • Date of Birth*
     - -
  • Gender*
  • Marital Status*
  • Date Last Seen by PCP (Required for patients with Medicare):
     - -
  • How did you hear about us?

  • Contact Information:

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • What if your preferred method of communication?*

  • Insurance Information:

  • Format: (000) 000-0000.
  • Is this a work-related injury? If yes, please provide the following:*

  • Acknowledgment of Receipt of Notice of Privacy Practices

    I acknowledge that I was provided a copy of the Notice of Privacy Practices from Foot and Ankle Center of Frisco/Little Elm and that I have read (or had the opportunity to read if, I chose so) and understood the Notice. 

  • Today's Date:*
     - -

  • Past Medical History:

  • Have you ever had any of the following? Check all that apply.*
  • Are you diabetic? (If no, please answer no and disregard the next few questions.)*
  • How do you control the diabetes?
  • Are you taking insulin?

  • Social History:

  • Do you consume alcoholic beverages?*

  • Family History (Blood Relatives):

    Please choose all that apply for each family member.
  • Mother*
  • Father*
  • Brother
  • Sister
  • Maternal Grandmother
  • Maternal Grandfather
  • Paternal Grandmother
  • Paternal Grandfather
  • Allergies:*
  • Do you have vascular grafts?*
  • Do you have replacement heart valves?*
  • Are you currently under active chemotherapy?*
  • Have you or a family member ever had malignant hyperthermia?

  • Primary Concern/Previous Treatments:

  • Please choose one of the following that describes your discomfort.*
  • Is this due to a motor vehicle accident?*

  • Consent for Treatment:

  • I,   *   *  , 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.

  • Today's 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?*
  • Today's 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.

  • 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?*

  • 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.

  • Today's 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. 

  • Today's 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.*

  • Medical Records Release Form:

  • By signing this form, I authorize you to release confidential health information about me by releasing a copy of my medical records, or a summary or narrative of my protected health information to The Foot and Ankle Centers of Frisco/Little Elm.

  • The information you may release subject to this signed release is as follows:*

  • Release my protected health information to the following entity: 

     

    Foot and Ankle Center of Frisco

    5375 Coit Road, Suite 100

    Frisco, TX 75035

    (P): 972-712-7773, (F): 972-712-3134 

     

     

     

  • I attest that the information above is both accurate and honest. 

  • Should be Empty: