Family Foot Care Patient Registration Secure Form (April 2024 Update)

Family Foot Care Patient Secure Registration
First
Last
Middle
Birthdate

MonthDayYear
Date
Age
Who is your primary care doctor/family doctor?
Last date seen primary doctor

MonthDayYear
Date
Whom may we thank for referring you?
Sex

MaleFemale
Race

CaucasianAfrican AmericanHispanicAsianOther
Email Address
example@example.com
Mailing Address
Street
City
State
Zip Code
Home Phone
Cell Phone
Work Phone
Social Security #
Do you prefer text or voice appointment reminders?

TextVoice
Employer
Patient's Occupation
Employer Mailing Address
If Married, Name of Spouse
Spouse Date of Birth

MonthDayYear
Date
Spouse Employer
Spouse Phone Number
In Case of Emergency, contact:
Phone
Relationship
Insurance Information (must present insurance card)
Primary Insurance
Insurance ID Number
Who is the Insured?
Insured Date of Birth:

MonthDayYear
Date
Secondary Insurance
Insurance ID Number
Who is the Insured?
Insured Date of Birth:

MonthDayYear
Date
l understand that if any of the insurance information have provided in incorrect or if fail to notify the office of any insurance changes, am responsible for all physician charges. I hereby authorize the release of any medical information necessary for the processing of insurance. Thereby assign all medical and/or surgical benefits to include major medical benefits to which am entitled to Family Foot Care. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original. Thave reviewed this information and is correct to the best of my knowledge.
Patient Name

First NameLast Name
Patient Signature

Clear
Date

MonthDayYear
Date
If Minor, Parent Signature:

Clear
Date

MonthDayYear
Date
Patient History
Name
Date

MonthDayYear
Date
Briefly describe your symptoms/area of pain
Date symptoms began

MonthDayYear
Date
Do you drink alcohol?

YesNo
Do you smoke?

YesNo
Former smoker?

YesNo
Do you Vape?

YesNo
Weight
Height
Check any that apply:

Aids/HIVAnemiaArthritisAsthmaCancerThyroid problemsStrokeHeart DiseaseHepatitisHigh Blood PressureArtificial Heart ValveHistory of GoutLow blood pressureEpilepsyDiabetes
What was your last A1C?*
Previous surgeries or surgical procedures (check all that apply):

FootAnkleArmHandKneeHipBackLiverKidneyNeckCancerOther
Are you now or have you been under any other doctor's care during the last year?

YesNo
If yes, explain
Family History of Mother:
Diabetes

YesNo
Heart Disease

YesNo
Family History of Father
Diabetes

YesNo
Heart Disease

YesNo
Other:
CURRENT MEDICATIONS: (all prescriptions, vitamins, over the counter medications)
Do you take blood thinner?

YesNo
Pharmacy Name
Pharmacy City
Pharmacy Phone Number
List all drug allergies and any reaction
Check here if you have NO MEDICATION ALLERGIES

No Allergies
I certify that the above information is true and correct to the best of my knowledge. give permission to the doctor to administer and perform such procedures as may be necessary in the diagnosis and/or treatment of my feet:
Patient (or parent of minor child) Signature

Clear
Date

MonthDayYear
Date
Patient Authorization for Contact
Patient Name (please print)
Purpose of Request:

I authorize Family Foot Care to disclose my protected health information in the following manner:
Home Telephone
Leave detailed messages on my voicemailLeave messages with only call-back number (includes staff member name and doctor's office name) on my voicemail
Can we call your name in the lobby?

YesNo
I give my permission to discuss any information from Family Foot Care with the following person/s
Name
Relationship
Name
Relationship
Name
Relationship
Patient Communication Transmittal Consent Form
Our doctors strive to maintain detailed and accurate medical records of your health care. This goal requires both verbal and written data to be entered into your medical record not only by physicians, but also by office staff, nurses and medical scribes. Verbal communication may be monitored during your visit to enable such detailed and accurate records to be created in a timely manner. All such communication is confidential and protected in order to maintain the privacy of your health information. By your signature below, you agree and consent to such monitoring for recordkeeping purposes. If you do not wish to have such communication monitored, you may opt out of the transmission by informing your physician of such decision.
I, (print name) agree and consent to the monitoring of verbal communications between myself and my physician for record keeping purposes.
Patient Signature

Clear
Date

MonthDayYear
Date
If Minor, Parent Signature

Clear
Date

MonthDayYear
Date
Financial Policy
All deductibles, co-pays, and co-insurance are due at the time services are rendered. Payments can be made by check, cash, Visa, MasterCard, or Discover.

If you have medical insurance, a claim will be filed with your insurance. Our office participates in many insurance plans. This means a discounted fee is accepted for many services. The co-pays, deductible, and co-insurance that are deducted from the final allowable fee are the responsibility of the patient or parent if patient is a minor.

These allowable fees with insurance companies can (and will) change often. Many change these “allowable fees” throughout various months of the year, while Medicare usually changes on a calendar year. Since these are somewhat un-predictable, there may be a balance after your insurance pays their amount.

A statement will be sent for any remaining balance. After 90 days any unpaid amounts will have a $20.00 collection fee added and will be forwarded to a collection service. Further interest and fees will be added through assigned collection service accordingly to their policies.

Cancellations: We require a 24-hour notice if you must cancel of reschedule your appointment. If you cancel the same day as your appointment, this will be considered a missed appointment. We reserve the right to charge a $50.00 fee for no-show/late cancellations.

No-Call / No-Show: 3 no-call/no-show appointments will be grounds from dismissal from the practice. Upon your request and written authorization, we will release your records to the doctor of your choice.

The cancellation and no-show fee are the sole responsibility of the patient and must be paid in full before the patient’s next appointment.
Patient: (print name)
Signature

Clear
Date

MonthDayYear
Date
If Minor, Parent Signature

Clear

Family Foot Care Patient Secure Registration

Mailing Address

Insurance Information (must present insurance card)

Patient History

Family History of Mother:

Family History of Father

Patient Authorization for Contact

Patient Communication Transmittal Consent Form

Financial Policy