• Ankle & Foot Specialists of Puget Sound, P.S. Patient Information Form

  • Today's Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Gender*
  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Responsible Party (ONLY FOR MINORS)

  • Responsible Party Gender
  • Responsible Party Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Were you referred to us?
  • Format: (000) 000-0000.
  • Subscribers DOB*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Subscribers DOB
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date of Injury
     / /
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.

  • I consent for medical treatment and have verified the insurance listed on this form is accurate. I authorize my insurance benefits be paid directly to Ankle & Foot Specialists of Puget Sound. I am financially responsible for all/any patient responsibility. I authorize the Physician/Facility or the Insurance Company to release any information required for this claim to be processed. We are a fee for service provider for all medical care received. l understand that I may be charged a $75.00 no-show fee if 24-hour notice is not given.

    "We are not a Multicare Facility, we are a Private Practice

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

  • Medical Information

  • Date*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Are you Diabetic?
  • I give my permission to this Medical office to pull my Prescription History Electronically through my Pharmarcy
  • Allergies*
  • Family History
    Rows
  • Family History*

  • *Surgical History

    Please include all in the last 10 years, same day surgery's & C- sections. Regardless of foot/ankle related:

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

  • Recreational Habits

  • Alcohol*
  • Alcohol Consumption*
  • Tobacco*
  • Former Tobacco User Quit Date
     / /
    2 digit month, 2 digit day, 4 digit year

  • Medical Conditions

  • Medical Conditions*

  • Ankle & Foot Specialists of Puget Sound, P.S.

  • NOTICE OF PRIVACY PRACTICES - ACKNOWLEDGEMENT

    My signature below acknowledges that I have been offered a copy of the Notice of Privacy Practices or directed to read the posted copy and verify that the information provided below is true.

    We may need to contact you regarding your healthcare. The information would be concerning appointments, orthotics, surgery, insurance benefits, etc.

    AI Scribe Documentation Notice:
    Our providers may use a secure, HIPAA-compliant AI medical scribe to assist with documenting your visit. This tool records and transcribes portions of the encounter to help your provider focus more directly on you. All information is encrypted, used solely for clinical documentation, and reviewed and finalized by your provider.

     

  • May we leave a message with specific information?*
  • May we leave a message with people answering this number?*
  • If yes, is there someone specific to leave it with?*
  • Date*
     / /
    2 digit month, 2 digit day, 4 digit year
  •  
  • Should be Empty: