louisvillefootandanklespecialists.com

Patient Name*

First NameMiddle NameLast Name

SSN*

Address*

Street Address

Street Address Line 2

CityState

Zip Code*

Birth Date*

Date

Age*

Gender*

MaleFemale

Marital Status*

Mobile Phone*

Please enter a valid phone number.

Home Phone*

Please enter a valid phone number.

Email*

example@example.com

Employer*

Occupation/Position*

Is the patient above the insurance policy holder on the account?

YesNo

Name

First NameLast Name

Relationship to Patient

Address

Street Address

Street Address Line 2

CityState

Zip Code

Home Phone

Please enter a valid phone number.

Company

Subscriber Name

Policy Number

Group Number

Company

Subscriber Name

Policy Number

Group Number

Have you ever been treated by a Podiatrist?

YesNo

Podiatrist’s Name

Emergency Contact Name

Emergency Contact/Phone

Please enter a valid phone number.

How did you hear about Louisville Foot & Ankle Specialists?

General Health:

ExcellentGoodFairPoor

Shoe Size:

Width:

Height:

Weight:

Recent Glucose

If Diabetic: A1C

Do you currently have, or have you previously had the following? Also indicate if you have a Family History of these conditions.:*

	YES	NO	Family History
Anemia
Arthritis
Diabetes
Gout
Hypertension
Stroke
Cardiovascular (Heart) Disease
Respiratory (Breathing) Problems
Gastrointestinal (Stomach) Distress
Urinary (Kidney) Problems
Bleeding Disorders

Are there any other medical conditions we should be aware of? Please specify if so:

What is the foot/ankle condition that you brings you to our office? Which side (left/right) Please explain:*

0/200

How long has this been an issue?

0/50

Is it getting worse, getting better or staying the same?

0/50

Describe how it feels:

0/50

What makes it worse / better?

0/50

What self-treatment, medical care or surgery have you had?

0/50

Have you ever been treated for infectious disease (HIV, Hepatitis, MRSA, etc)?*

YesNo

If yes, explain:

Are you pregnant?*

YesNo

Do you smoke?*

YesNo

How many packs per day?

For how many years?

Do you drink alcohol?*

YesNo

Do you use illegal drugs?*

YesNo

What medications are you taking? (Feel free to bring your list)*

Allergies:*

Family Doctor*

Pharmacy*

Pharmacy Phone*

Please enter a valid phone number.

Zip*

I hereby request and give permission to Louisville Foot & Ankle Specialists and whomever Louisville Foot & Ankle Specialists may designate as assistants, to administer treatment, and to perform such general procedures as Louisville Foot & Ankle Specialists may deem to be necessary in the diagnosis and/or treatment of my foot complaints.
AUTHORIZATION: I hereby authorize the release of any medical information necessary to process my insurance. I authorize payment directly to the provider of services. I understand that I am financially responsible for any remaining or unpaid balances.
I further authorize the release of any medical information to other doctors treating me.
I further authorize payment of Medicare and/or other insurance benefits to Louisville Foot & Ankle Specialists for the services performed.
I give my consent to have photographs and/or videotaped images taken for teaching purposes, advertising and digital/print publication. If utilized, the patient name and all identifiers will be kept confidential.
I acknowledge that I will be provided a copy of the Notice of Privacy Practices (if requested) and that understand this notice. This notice may be found at: LouisvilleFootAndAnkleSpecialists.com.
I give my consent for the practice to contact me at the address /and or phone number provided. Voicemail and text messages may be utilized.

NOTICE OF CANCELLATION POLICY

I understand that I am responsible for my appointment time(s) and that should I not give notice of cancellation of my appointment at least 24-hours before that appointment, I may be charged a $25.00 fee.
After two no-shows, the practice reserves the right to no longer schedule future appointments.
These policies are to allow our office to run more efficiently and on time.

Patient Signature*

Date and time*

Date

Hour MinutesAM/PM Option

Parent or Authorized Representative (if applicable) If this is not being submitted by patient:

New Patient Form

PATIENT INFORMATION

PARTY RESPONSIBLE FOR PAYMENT OF THE ACCOUNT

PRIMARY INSURANCE INFORMATION

SECONDARY INSURANCE INFORMATION

OTHER INFORMATION

Medical History