New Patient Paperwork

Responsible Party (ONLY FOR MINORS)
Responsible Party Last Name
Responsible Party First Name
Responsible Party Middle Initials
Responsible Party Gender
Responsible Party Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Primary Care Doctor
Were you referred to us?
If Yes, By whom
Emergency Contact
Emergency Contact Phone Number
Format: (000) 000-0000.
Relationship to Patient
Primary Insurance
ID# (LETTERS & NUMBERS)
**PLEASE INCLUDE ALL LETTERS AND NUMBERS**
Grp#
Name of Subscriber
Relation to Patient
Subscribers DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Employer
Secondary Insurance
ID#
**PLEASE INCLUDE ALL LETTERS & NUMBERS**
Grp#
Name of Subscriber
Relation to Patient
Subscribers DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Employer
Is this visit a Workers Comp Injury or Auto Accident?
Date of Injury

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Relationship (if minor)

Medical Information
Patient Name
DOB
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Height
Weight
Shoe Size
Width
Location of Issue (Can choose multiple)
What is the Foot or Ankle Problem that brings you to our office? (Please be specific as RIGHT or LEFT) (Fracture, Sprain, General Pain, Tendonitits, Toenail Fungus, Callus, Ulcer/Wound)
Pharmacy Name
City
Pharmacy Phone #
Previous Podiatric Doctor
City
Last Visit
I consent to have my Medication History Pulled Electronically from my Pharmacy:

Ankle & Foot Specialists of Puget Sound, P.S.
Patient Name
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.
May we leave a message with specific information?
Authorized Phone Number(s)
May we leave a message with people answering this number?
If yes, is there someone specific to leave it with?
Name(s) of authorized Individual(s)
Patient or Authorized Individual Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Printed Name of Above Signer
Relationship
Should be Empty: