• New Patient Information

  • Sex
  • Marital Status

  • Emergency Contact

  • Primary Care Physician

  • Ethnicity
  • Race:

  • How did you find out about our practice?

  • Finances and Billing

    (If patient is a child or dependent adult, please give name of responsible party for finances and billing)

  • Date of Birth
     / /
    2 digit month, 2 digit day, 4 digit year

  • Insurance Information

  • Policy Holder Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Secondary Carrier Policy Holder Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Is this a compensation or work-related case? ̈ Yes
  • Date of Accident
     / /
    2 digit month, 2 digit day, 4 digit year
  • Are you interested in Laser Treatment for Toenail Fungus?

  • I hereby give the above named doctor permission to administer the necessary treatment in order to diagnose and treat my present foot condition, after it has been explained to me.

  • Date
     / /
    2 digit month, 2 digit day, 4 digit year

  • Past Medical History

  • Today's Date
     / /
    2 digit month, 2 digit day, 4 digit year
  • Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Any prior imaging?
  • Allergies/Reaction

  • Smoking History

  • Tobacco User
  • Smoking Frequency
  • Past Medical History (Indicate if you have had any of the following)

  • Social History

  • Alcohol Use
  • Drug Use
  • Exercise Habits
  • Download or print the Financial Policies PDF, then sign below to accept the terms.
  • Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Download or print the Privacy Policies PDF, then sign below to accept the terms.
  • I grant permission to:
  • Should be Empty: