• WELCOME To The Foot Care Centers

  • Date:
     - -
    2 digit month, 2 digit day, 4 digit year

  • Patient Information

  • Best Number to reach you
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Birth date 
     - -
    2 digit month, 2 digit day, 4 digit year
  • Please Circle One
  • Please Circle One
  • Please Circle One

  • Employer Information

  • Format: (000) 000-0000.

  • Spouse/Parent/Guardian Information   

  • Date of Birth   
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.

  • Emergency Contact Information

  • Contact # 1

  • Format: (000) 000-0000.

  • Contact # 2

  • Format: (000) 000-0000.

  • Insurance Information  

    Please Present All Insurance Cards
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year

  •  Primary Insurance

  • Policy Holder - Who is the insurance through?

  • Policy Holder’s Date of Birth  
     - -
    2 digit month, 2 digit day, 4 digit year
  • Referral Required (Please circle one)

  • Secondary Insurance

  • Policy Holder - Who is the insurance through?

  • Policy Holder’s Date of Birth  
     - -
    2 digit month, 2 digit day, 4 digit year
  • Referral Required (Please circle one)

  • Primary Care Physician

  • Format: (000) 000-0000.
  • Why did you choose our office?

  • SIGNATURE REQUEST FOR INSURANCE BILLING

    Release: I hereby authorize the release of any information acquired in the course of my examination which said insurance company may request.

    Responsibility & Assignment: I also assign and request payment of medical benefits to the above stated physician or supplier for medical services. I also understand that I am financially responsible for payment of my bill.

  • Office Policies

  • Thank you for choosing the Foot Care Centers.  We will strive to give you the excellent professional care you deserve as our patient and friend.

    We want to make your experience at the Foot Care Centers a pleasurable one.  Please be aware of the procedures and policies of this office as stated below.  Should you have any questions or do not understand something, please ask one of our staff members.

    Co-Payments
    All co-payments will be collected at the time of check-in.  Your insurance company requires that you pay your co-pay at the time of your visit.  Patients who fail to do this are in direct violation of their contract with their insurance company.

    If you are unable to pay your co-pay at the time of your visit, we will need to reschedule your appointment.

    Referrals
    Patients will be advised if a referral is required for their next schedule visit.  It is the responsibility of the patient to obtain this referral from their primary care physician prior to the visit.  If you do not have your referral with you at the time of check-in, we will need to reschedule your appointment.

    Foot Care Center is not permitted to call your primary care physician to obtain a referral for you.

    Cancellation Policy
    If you are unable to keep your appointment, you must call to cancel at least one full business day prior to your scheduled appointment time.  Any patient who does not show up for their appointment or cancel with in the specified time frame will be billed for an office visit.

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

  • According to New Jersey insurance company guidelines, these questions must be answered.

  • Do you have an Advance Directives/Living Will? (For patients 18 and above)
  • Do you use illegal drugs
  • Do you have the following barriers that would prevent your care? (Please Circle)
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

  • I acknowledge that I was provided a copy of the Notice of Privacy Practices and that I have read (or has the opportunity to read if I so choose) and understood the Notice.

     

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

  • I authorize Foot Care Centers/ Affiliated Podiatrists of South Jersey, to obtain any protected health information from health care professionals who are involved in my care.

  • Should be Empty: