• New Patient Form

  • Today's Date:
     - -
  • DOB:
     - -
  • Marital Status:
  • Sex:
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Primary Insurance:

  • Are you the insured:

  • Insured Information

  • Format: (000) 000-0000.
  • Relationship to Insured:
  • Format: (000) 000-0000.
  • Sex:
  • DOB:
     - -

  • Secondary Insurance:

  • Are you the insured:

  • Insured Information

  • Format: (000) 000-0000.
  • Relationship to Insured:
  • Format: (000) 000-0000.
  • Sex:
  • DOB:
     - -
  • How did you find out about our practice?
  • Reason of accident or work injury?
  • How long has this bothered you?
  • The pain quality is:

  • PLEASE READ AND SIGN

    The above information is correct to the best of my knowledge. I understand that throughout my treatment, I am responsible for notifying the physician and/or medical staff of any and all updates to the information and listed above. 

  • Date:
     - -
  • Today's Date:
     - -
  • Date of Birth:
     - -
  • Ethnicity:
  • Race:
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Date Last Seen:
     - -
  • Format: (000) 000-0000.
  • Date Last Seen:
     - -

  • Privacy Information Preferences

  • Do you want to be exempt from public reporting?
  • Can we send mail to the address on file?
  • Can we call the phone number on file?
  • Can we leave voicemail on machine?
  • Will you allow us to send internet based (e-mail) delivery of reminders and newsletters?
  • Who can we leave messages with?
  • Smoking Status

  • Vital Signs

  • Current Medications:
  • Allergies:
  • Last Flu Shot Date:
     - -
  • Did you get a pneumococcal vaccination?
  • Have you fallen in the last 12 months?
  • Were you injured from the fall?
  • Advanced Directives:

  • PLEASE READ AND SIGN:

    The information on my intake form(s) is correct to the best of my knowledge. I understand that throughout my treatment, I am responsible for notifying the physician and/or medical staff of any and all updates to the information listed above. (Assignment and Benefits): I authorize payment of medical benefits to the practice named above. (Release of Information): I authorize the release of any medical information necessary to process this claim. (HIPAA Privacy): I acknowledge that I received my HIPAA Privacy Practices Notice. (Medication History): I authorize the Doctor's office to retrieve my medication history.  

  • Date:
     - -

  • History and Physical

  • DOB:
     - -

  • Medical History:

  • Please check all that apply
  • Are you pregnant?
  • Are you nursing?

  • Surgical History

  • Please check all that apply
  • Have you ever had any surgical procedures on foot/ankle or anywhere else on your body?
  • Do you have any artificial joints?
  • Do you have any artificial heart valve?

  • Social History

  • Do you smoke?
  • If yes how many packs per day?
  • Do you drink alcohol?
  • Substance abuse:
  • Does it involve mostly
  • Do you exercise regularly?

  • Family History

  • Rows

  • Review of Systems

    Please check the box if you currently have any of these symptoms or check "None"
  • Cardiovascular
  • Genitourinary
  • Gastrointestinal
  • Integumentary
  • Hematologic
  • Neurological
  • Musculoskeletal
  • Respiratory

  • PLEASE READ AND SIGN

    The above information is correct to the best of my knowledge. I understand that througout the treatment. I am responsible for notifying the physician and/or medical staff of any and all updates to the information listed above. 

  • Date:
     - -

  • David N, Gavin, DPM, FACFAS
    15620 McGregor Blvd., Suite 125
    Fort Myers, FL 33908
    Office: 239-887-4621
    Fax: 239-887-4623

    David N Gavin, DPM, FACFAS
    Board Certified, American Board of Podiatric Surgery
    Fellow American College of Foot and Ankle Surgery

  • Date of Birth:
     - -

  • HIPPA
    Health Insurance Portability Accountability Act

    NOTICE OF PRIVACY PRACTICES PATIENT ACKNOWLEDGEMENT

    I understand that under the Health Insurance Portability Accountability Act of 1998, I have certain
    rights to privacy in regards to my protected health information (PHI). I have been offered a copy,
    and or read the contents provided in the office, and understand the Notice of Privacy Practice.

    David N. Gavin, DPM, FACFAS reserves the right to change the terms of it's Notice of Privacy
    Practice. I understand the Practice will provide a current Notice of Privacy upon request.

  • Date:
     - -

  • Advance Beneficiary Notice of Noncoverage (ABN)

  • NOTE: If Medicare doesn't pay for D.      below, you may have to pay. Medicare does not pay for everything, even some care that you or your health care provider have good reason to think you need. We expect Medicare may not pay for the D.      below.

  • Rows

  • WHAT YOU NEED TO DO NOW:
    • Read this notice, so you can make an informed decision about your care.
    • Ask us any questions that you may have after you finish reading.
    • Choose an option below about whether to receive the D.      listed above.
    Note: If you choose Option 1 or 2, we may help you to use any other insurance that you might have, but Medicare cannot require us to do this.

  • G. Check only one box. We can't choose a box for you.

  • H. Additional Information:

    This notice gives our opinion, not an official Medicare decision. If you have other questions on this notice or Medicare billing, call 1-800-MEDICARE (1-800-633-4227,TTY: 1-877-486-2048).
    Signing below means that u have received and understand this notice. You also receive a copy.

  • Date:
     - -

  • CMS does not discriminate in its programs and activities. To request this publication in an alternative format, please call: 1-800-MEDICARE or email: AltFormatRequest@cms.hhs.gov. 

  • Patient Insurance and Payment Responsibility Contract

  • The staff is fully committed to providing you with the best service and medical care while under our care. We understand that insurance billing and patient responsibility can sometimes be challenging to understand. To ensure you fully understand and comply with our payment policy we require all patients review and sign this contract prior to seeing the doctor for the initial visit. Please read carefully and initial each line.

  • Insurance
  • PAYMENT COLLECTION RULES

  • The undersigned hereby obligate him/her to pay the patient account balance, as mention above, for the medical services rendered. If this account is referred to the collection agency for payment, the undersigned agrees to also to pay the collection fees of 30% in conjunction with the delinquent account.

  • Date:
     - -
  • Should be Empty: