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

Responsible Party (ONLY FOR MINORS)

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 $25.00 no-show fee if 24-hour notice is not given.

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

Medical Information

*Surgical History

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

Recreational Habits

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.