• New Patient Form

    Note: if you'd like to download a printable PDF instead of filling out the online form, please click here.

  • General Information

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Weight*
  • Height*
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  • Primary Care Physician

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

  • Pharmacy

  • Format: (000) 000-0000.

  • Emergency Contact

  • Format: (000) 000-0000.

  • Referral Source

  • How did you hear about our practice?*

  • Insurance Information

  • Will you be using insurance for your visit?*

  • Primary Insurance

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  • Format: (000) 000-0000.
  • Primary Subscriber - Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Primary - Referral Needed*

  • Secondary Insurance

  • Do you have secondary insurance*
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  • Format: (000) 000-0000.
  • Primary Subscriber - Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Secondary - Referral Needed

  • Medications & Allergies

  • Medications
  • Allergies*

  • Family History

  • Rows

  • Past Medical History

  • Select all that apply
  • Diabetes Treatment(s)*

  • Social History

  • Do others depend on you for their care?*
  • Have you ever smoked?*
  • Do you drink?*
  • Do you use recreational drugs?*
  • Are you pregnant?*
  • Are you claustrophobic?*

  • Past Surgical History / Hospitalizations

  • Select all that apply*
  • List details for all selections above
  • Have you had any complications with anesthesia in the past?*

  • History of Current Condition

  • Where is the pain / problem located? Please mark on the pictures below.
  • Is the condition a result of an injury?*
  • Date of Injury*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Injury classification*
  • Description of pain (select all that apply)*
  • Have you experienced this problem in the past?*
  • What treatments have you tried? (select all that apply)*
  • Have you seen another doctor for this problem?*

  • Review of Symptoms

    Select all symptoms you are currently experiencing
  • General
  • Cardiovascular
  • Endocrine
  • ENT
  • Gastrointestinal
  • Genitourinary
  • Hematology
  • Musculoskeletal
  • Neck
  • Neurological
  • Psychiatric
  • Respiratory
  • Skin
  • Vascular

  • Patient Assessment

  • The physicians at Signature Foot & Ankle are concerned about your overall health and wellbeing and are evaluating factors in which may impact your overall health and orthopedic health. The following questions are intended to give the physicians information about your general health.

  • Have you been fully vaccinated for COVID-19?*
  • Have you had a bone density study (DEXA scan) for osteoporosis at least once since 60?*
  • Have you been on medicine to treat osteoporosis?*
  • Has your osteoporosis medicine been prescribed within the last 12 months?*
  • Do you take Calcium?*
  • Do you take Vitamin D?*
  • Have you fallen more than twice or fallen and hurt yourself in the past year?*
  • Have you had the influenza vaccine for the current flu season?*
  • Have you had the pneumococcal vaccine?*
  • Do you have an Advanced Care Plan?*

  • Signature of Patient / Guardian

  • To the best of my knowledge, I have answered the questions on this form accurately. I understand that providing incorrect or incomplete information can be dangerous to my health. I understand that it is my responsibility to inform the doctor and office staff of any changes in my medical status. Parent or legal guardian name and signature required for individuals under age 18.

  • Photo and Promotional Release Form

  • I understand that photographs, videotapes, digital, or other images may be recorded to document my care, and I consent to this. I understand that Signature Foot and Ankle will retain ownership rights to these photographs, videotapes, digital, or other images, but that I will be allowed access to view them or obtain copies. I understand that these images will be stored in a secure manner that will protect my privacy and that they will be kept for the time period required by law or outlined in Signature Foot and Ankle’s policy. Images that identify me will be released and/or used outside the institution only upon written authorization from me or my legal representative.

    I give my consent to have photographs, videotaped images, or other images made during the visit. I understand and agree that these images may be used by Signature Foot and Ankle for the purpose outlined below. They will not include any identifiable features when used outside of my chart. This includes, but is not limited to: Teaching purposes, which includes being shown to other patients, residency, and research. Advertisements for Signature Foot & Ankle.

  • Disclosure of Health Information

    Consent to use and disclosure of health information for treatment, payment, or healthcare operations

  • Our Notice of Privacy Practices provides information about how we may use or disclose protected health information.

    The notice contains a patient’s rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent.

    The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date.

    You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations. 

    By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive.

    By signing this form, I understand that:

    • Protected health information may be disclosed or used for treatment, payment, or healthcare operations.
    • The practice reserves the right to change the privacy policy as allowed by law.
    • The practice has the right to restrict the use of the information but the practice does not have to agree to those restrictions.
    • The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.
    • The practice may condition receipt of treatment upon execution of this consent.
  • May we discuss your medical condition with any member of your family?*
  • Please name the members of your family we can discuss medical conditionals with:*
  • Should be Empty: