New Patient Paperwork

Primary Care Doctor
I don't have a primary care doctor
YesNo
If Yes, By whom
Emergency Contact
Emergency Contact Phone Number
Format: (000) 000-0000.
Relationship to Patient
Primary Insurance*
ID#*
Grp#*
Name of Subscriber*
Relation to Patient*
Subscribers DOB*

MonthDayYear
Date
Subscribers DOB
Employer
Secondary Insurance
ID#
Grp#
Name of Subscriber
Relation to Patient
Subscribers DOB

MonthDayYear
Date
Subscribers DOB
Employer
Is this visit Injury Related?
Date of Injury

MonthDayYear
Date
Work/Auto/Other
Employer at time of injury
Claim #
Claim Manager
Claim Manager Phone Number
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
Signature*

Clear
Date*

MonthDayYear
Date
Relationship (if minor)

Medical Information
Patient Name*
DOB*
Date*

MonthDayYear
Date
Height*
Weight*
Shoe Size*
Width*
Width*
What is the Foot or Ankle Problem that brings you to our office? (Please be specific) (Left foot, left ankle, right ankle, right foot, etc)
Pharmacy Name*
City*
Pharmacy Phone #*
Family Doctor
City
No Family Doctor
Previous Podiatric Doctor
City
Last Visit