Patient Information

Affiliated Foot & Ankle, P.C.

Buckhead: 3025 Maple Drive - Suite 2, Atlanta, GA 30305; Midtown: 619 Rankin Street NE, Atlanta, GA 30308 Buckhead/Midtown phone: 404-231-1227; fax: 404-364-0834; www.GApodiatry.com Duluth: 3071 Peachtree Ind. Blvd - Suite 110, Duluth, GA 30097 Duluth phone: 770-232-9778; fax: 770-232-9776; www.GApodiatry.com

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Today's Date

Month Day Year
Patient's Full Name *
Date of Birth

Month Day Year
Date
Patient Address *

Street Address 1

Street Address 2

City State

Zip
Email
Patient's Home Phone *
Cell Phone *
Social Security Number
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Employer
Work Phone
Marital Status

Single Married Divorced Widowed/Widower Domestic Partnered
Gender

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Pharmacy
Pharmacy Phone #
Pharmacy Address
If under 18 years old, parent's name
Insurance Company Name *
Policy Holder *
If you are self pay, siimply put in your Date of Birth for both the policy & group numbers.
Date of Birth of Policy Holder *

Month Day Year
Policy Number *
Group Number *
Emergency Contact Name
Relationship to Patient
Emergency Contact Phone
Secondary Emergency Contact Phone
Whom May We Thank For Referring You To The Practice?
Primary Care Physician (First & Last Name)
Phone Number
Date Last Seen In Primary Care Physician' Office (Please be as specific as possible)
Physician's Office Address
Signature of Patient or Guardian *

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Date *

Month Day Year
Date
Medical Health History
Name
Gender
Age
Race
Preferred Language
Ethnicity
What Type of shoes do you wear?
Shoe Size *
Height
Weight
What is the reason for your visit today? *
Where on your foot/ankle/leg is your problem? *
How long has it been a problem (days, weeks, months, years)?
ls it getting better, staying the same, or is it worse?
How did it start, did you have an injury or any other inciting event/trauma?
What makes it better?
What makes it worse?
What treatment have you or another doctor tried, if any?
If you had to rank your pain from O to 10, (0 = no pain, 1O =severe, how would you rank your pain level? *
If you have pain, is it sharp, stabbing, dull ache, throbbing, burning, etc?
Was this a work related accident?

Yes No
If so, date of accident

Month Day Year
Date
What activities do you participate in (sports, gardening, etc.)?
Any other relevant information pertaining to your problem today?
Past Medical History: Please indicate if you've ever had *

NONE High blood pressure Heart disease / Pacemaker Angina Heart Failure Mitral Valve Prolapse Liver Cancer Irregular Heartbeat (Type? Explain Below) Murmur (Type? Explain Below) Seizures / Epilepsy Neurologic disorders Tuberculosis Asthma/Bronchitis/ COPD Pneumonia Emphysema Sleep Apnea CPAP Use Hyperthyroid (high) Hyperthyroid (low) Hormone / Gland Problems Hepatitis (Type? Explain Below) Liver disease / cirrhosis Liver jaundice Gallbladder disease Kidney infection Kidney stones Chronic Kidney Disease Renal (Kidney) failure / insufficiency Urinary/Bladder infection Prostate disease Gynecological disorders Stomach ulcers Stomach bleeds Hiatal hernia Gastro-esophageal reflux Colon cancer Intestinal disease Cancer Anemia Bleeding problems High cholesterol Blood clots in legs/ lungs Arthritis (Type? explain below) Skin disorder ( Type? explain below) AIDS or HIV+ Joint pain / stiffness Psychiatric disorders (explain below) Depression or Anxiety Problems with anesthesia Bypass Heart Bypass Legs Diabetes Type 1 (Please Note Number of Years Below) Diabetes Type 2 lease Note Number of Years Below) Neuropathy Stroke Heart Attack (MI) Immune Disorder Type (Explain below)ONE
List other medical conditions - (Please type NONE, if not applicable) *
Please list all medications & OTC medications, including how you take it and the dose.(Please note NONE if not applicable) *
Please list all surgeries and year of surgery - Please type None, if not applicable *
Please list all drug allergies and reaction, rash or throat closing, etc. (Please note NONE if not applicable) *
Social History
How frequently do you drink beer, wine, and / or liquor?
Do you smoke? How many packs / cigars a day? How many years? - Please type No, if not applicable *
Are you a current non-smoker, but used in the past? How long ago did you quit?- Please type No, if not applicable *
Do you take any illicit or recreational drugs- Please type No, if not applicable? *
WOMEN ONLY: Is there a chance you could be pregnant?
Family History

Please list your parents health problems and if alive or deceased.
Mother
Father
List Any Family Health Problems (Diabetes? Heart disease?)
"I certify that the above information is true and correct to the best of my knowledge. I give my permission to the doctor to administer and perform such procedures as may be deemed necessary in the diagnosis and/or treatment of my feet, leg, and/or ankles."
Please sign form here *

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Date *

Month Day Year
SUMMARY OF NOTICE OF PRIVACY PRACTICES
HEALTH INFORMATION USE AND DISCLOSURE

The offices of Dr. Mistretta, Dr. Filiatrault, and Dr. Hill understand that medical information about you and your health is personal and we are committed to protecting that information. With that understanding, we will use and disclose your health information for the following purposes: to treat you, to assist other health care providers in treating you, to allow insurance companies to process insurance claims for services rendered to you, to obtain payment for services rendered to you and for certain limited operational activities such as quality assessment, licensing, accreditation and training of students. We will not use or disclose your health information without your written authorization, except as stated in more detail in the Notice of Privacy Practices. We reserve the right to change this notice and will post a copy of the current notices in effect in our facility.
ADDITIONAL DISCLOSURE AUTHORITY

In addition to the allowable disclosures described in the Notice of Privacy Practices, if you would like to authorize the disclosure of your protected health information to another person(s) please specify by answering the questions below. In regards to your protected health information, are we allowed to speak with (please check):
Any member of your immediate family? *

Yes NO
Your spouse/partner *

Yes NO
Name
Other *

Yes NO
Name
Can we leave messages regarding your health information on your voicemail / answering machine? *

Yes NO
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

I acknowledge that I was provided a copy of the Notice of Privacy Practices and have read (or had the opportunity to read if I so chose) and understood the Notice.
Patient Name *
Name of Guardian/Authorized Representative (if applicable):
Signature of Patient or Guardian: *

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Date *

Month Day Year
FINANCIAL POLICY FOR AFFILIATED FOOT & ANKLE, PC

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INSURANCE PATICIPATION

In an effort to accommodate our patients, Affiliated Foot & Ankle participates with most insurance plans. Although we are pleased to provide services to our patients, it is impossible for our office staff to be aware of the specific benefits and requirements of each and every plan. There may be limitations under your plan on procedures, supplies, durable medical goods, numbers of office visits, laboratories you may use, referrals and authorizations for certain procedures. We ask that you please be familiar with your insurance contract regarding services, exclusions, and expiration dates for referrals. Unfortunately, if you do not inform us of special guidelines and limitations of your plan, and we subsequently order or perform services or procedures, these may be considered non-covered and will not be paid by the insurance company. Any service determined to be non- covered by your plan will be your responsibility. You are responsible for any, and all co-payments, deductibles, non-covered services, procedures, supplies, and coinsurances. Co-payments are due at the time of service. Once your insurance carrier has processed your insurance claim, you are responsible for ALL remaining balances. A statement will be sent and you will be responsible to remit ALL balances in full. Any special financial arrangements must be approved in writing from our business office. LATE FEE: There is a $25.00 late fee for all unpaid balances after 60 days past the date of service.
RETURNED CHECK FEE:

A fee of $30.00 will be assessed on any checks returned for insufficient funds. If we find it necessary to take collection action on your outstanding balance, you will be assessed an additional 30% collection fee to that amount or a minimum of $30.00
CANCELLATION OF APPOINTMENT:

Our office requires 24 hours notice if you are unable to make your appointment. Please notify us as soon as you are aware of any schedule changes. There will be a $35.00 fee for not complying with this policy. Your courtesy is deeply appreciated so that we may serve you and other patients more efficiently.
I have read theabove payment policy, understand the contents thereof, and agree by the terms set forth.
Patient Name *
Signature of Patient or Guardian: *

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Date *

Month Day Year
Should be Empty:

Medical Health History

Social History

Family History

SUMMARY OF NOTICE OF PRIVACY PRACTICES

HEALTH INFORMATION USE AND DISCLOSURE

ADDITIONAL DISCLOSURE AUTHORITY

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

FINANCIAL POLICY FOR AFFILIATED FOOT & ANKLE, PC

INSURANCE PATICIPATION

RETURNED CHECK FEE:

CANCELLATION OF APPOINTMENT: