drsafapour.com - New Patient Form

PATIENT MEDICAL HISTORY

Welcome to our office. Thank you for your attention to this form.
Name:
Age:
Are you allergic to any medication(s)?

YesNo
What medication(s)?
What Medication(s) are you taking now?

Do you have now, or have ever had, any of the following:

	Yes	No
Diabetes
High Blood Pressure
Kidney Problems (Nephritis)
Heart Disease (Stroke, Heart attack)
Gout
Rheumatoid Arthritis
Osteo Arthritis
Anemia
Stomach or intestinal problems (Ulcers, Colitis)
Liver Problems (Hepatitis)
Mental Disorders
Polio
Nerve/ Neurological Disorders (Paralysis, M.S., Epilepsy)
Pneumonia
Asthma or Bronchitis
Immune Deficiency Diseases
Chronic Infections (Throat, Bladder)
Cancer
Childhood Diseases
Skin Problems (Dermatitis, Psoriasis)
Vascular/ Circulatory Problems (Leg cramps, Varicose veins, Hardening of arteries)

Describe any of the above conditions you checked "Yes":
Have you had any surgeries in the past? (List type and date of each surgery)?
Detail any additional information you think may be helpful:

Any family history of?

	Yes	No	Who (i.e. Mother, Son, etc..)
Cancer
Heart Disease
Diabetes
High Blood Pressure

Do you smoke?

YesNo
Drink Alcohol?

YesNo
Are you pregnant?

YesNo
Do you drink antibiotics before surgery or dental work?

YesNo
Thank you taking the time to complete this questionnaire.
Patient's Signature

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PATIENT PERSONAL INFORMATION:
Name

First NameMiddle NameLast Name
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell #
Please enter a valid phone number.
Home #
Please enter a valid phone number.
Work #
Please enter a valid phone number.
Email
example@example.com
Social Security Number
Sex
Driving License #
Date of Birth

MonthDayYear
Date
Marital Status
Emergency Contact Name
Emergency Tel #
Please enter a valid phone number.
Emergency Relationship
How did you find out about us?

TVRadioYellow Pages
(Patient Referred By):
Doctor
Patient
Other
Race
Ethnicity
Preferred Language
INSURANCE INFORMATION:
Name of Insurance Company
Tel #
Please enter a valid phone number.
Insurance ID #
Group #
RESPONSIBLE PARTY INFORMATION:

Insurance Information
Name
Relationship to Patient
Address
Tel #
Please enter a valid phone number.
Date of Birth

MonthDayYear
Date
Social Security #
If Patient is a Minor, Name of Responsible Parent
I will be paying today by:

CashCheck
TREATMENT AGREEMENT

With regard to Podiatric care and service provide or to be provided, IT IS AGREED that: The ATTENDING PODIATRIST will provide podiatric care and services to the patient, to the best of his skill and knowledge which podiatric care in the light of cirumstance is possible and practical. THE PATIENT will cooperate fully with the ATTENDING PODIATRIST by obtaining such medications as are prescribed, by following the instructions of the ATTENDING PODIATRIST, by adhering to such treatment regimen or course of action as may be set forth, and by paying all fees and charges in full as billed or as provided by prior special arrangements IT IS AGREED that; Because of differences in human constitution and response, it is no way possible to warrant the outcome of such podiatric care and service. In the interest of good patient-doctor relationships, it is desirable to establish a good credit policy. An effective policy enables the doctor and patient to avoid misunderstandings.

I authorize the release of any podiatric information necessary to proces claims for podiatric services and request payment directly to the ATTENDING PODIATRIST and/or DR. MATTHEW SAFAPOUR, DPM. I understand that I am financially responsible for all charges not covered by my insurance benefits.
Patient Signature

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Date

MonthDayYear
Date
If the patient is a minor or incompetent, the parent or guardian should sign here, and in addition the minor of incompetent patient should sign above, if possible.
Parent or Guardian Signature

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Date

MonthDayYear
Date

ACKNOWLEDGEMENT
Physician: Dr. Matthew Safapour DPM

Telephone: (818) 986-9898

Address: 7325 Medical Center Dr. Suite# 307 West Hills, CA 91307
Patient's Name:
DOB:

MonthDayYear
Date
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone:
Please enter a valid phone number.
Advance Directives- The Patients Right to Decide

This acknowledgment that the physician or one of his/her staff members has provided me information concerning Advanced Directives.
1. I am age 18 or Older:

YesNo
2. I realize that I have the option of putting together Advanced Directives for my healthcare. My physician has provided me written concerning these Advanced Directives. I understand that it is my responsibility to provide my doctor(s) with any documents that are required to carry out my Advanced Directives.

3. I am aware that Advanced Directives may be any one of the following:

(a) A durable Power of Attomey for Health Care.
(b) The Declaration in the A natural Death Act-Ex. A Living Will
(c) I may write down my wishes on a piece of paper so that my family may use the document, in deciding my medical treatment, in the event I am unable to do so.
Patient Signature:

Clear
Date:

MonthDayYear
Date
This document will become part of my medical record.

Standard Authorization of Use and Disclosure of Protected Health Information
Information pertaining to Patient Name:
Date of Birth:

MonthDayYear
Date
Information may be disclosed or released by: Dr Matthew Safapour DPM, Staff and Employees. If specified, only the staff or employee named here may release or disclose information:
Information may be disclosed or released to:
This will expire in one year from the date signed, unless you specify a date less than one year from the date signed or unless terminated by the patient or patient's authorized representative. Specify expiration date if less than one year: Type a label The patient may revoke or terminate this authorization by submitting a written revocation to Dr. Matthew Safapour, DPM.

Potential for Redisclosure:
Information disclosed under this authorization may be disclosed again by the person or organization to which it is sent. The privacy of this information may not be protected under privacy regulation.
Patient Signature

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Signature of Patient Representative (if applicable)

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Date

MonthDayYear
Date
Relationship

CONSENT FORM

For TEXT Messaging, VOICE Messaging and Email
I First Name Last Name give permission to Dr. Matthew Safapour and his staff to
Text me Call me or Leave a Voice message and Email me

based on the information containing phone numbers and Emails I have provided them.
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

PATIENT MEDICAL HISTORY

PATIENT PERSONAL INFORMATION:

INSURANCE INFORMATION:

RESPONSIBLE PARTY INFORMATION:

ACKNOWLEDGEMENT

Standard Authorization of Use and Disclosure of Protected Health Information

CONSENT FORM