Shelby Foot Patient Information

Patient Information
Date*

MonthDayYear
Today's Date
Social Security#
Name*

First NameMiddle NameLast Name
Your Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Best Phone Number To Contact You*
Please enter a valid phone number.
Best Method and Time To Contact You*

EmailPhoneMorningAfternoonEvening
Gender at Birth*

MaleFemalePrefer Not To Answer
Age*
Date of Birth*
Marital Status*

MarriedSingleDivorcedWidowedSeparatedPartnered for () Years
In Case of Emergency, Contact

First NameLast Name
Emergency Contact Relationship
Emergency Contact Relationship
Please enter a valid phone number.
Occupation*
Patient Employer/School*
Patient Employer/School Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient Employer/School Phone Number
Please enter a valid phone number.
Spouse/Partner Name

First NameLast Name
Spouse/Partner Date of Birth

MonthDayYear
Date
Spouse/Partner Social Security Number
Spouse/Partner Employer
Please enter a valid phone number.
Reason for Today's Visit*
Insurance
Person Responsible for Payment of This Account*

First NameLast Name
Relationship to Patient*
Insurance Company Name*
Group Number*
Is Patient Covered By Additional Insurance?*

YesNo
Subscriber's Name

First NameLast Name
Subscriber's Birthdate

MonthDayYear
Date
Subscriber's Social Security#
Relationship to Patient
Insurance Company
Group Number
Insurance Assignment and Release
I certify that I have insurance coverage with Name of Insurance Company(ies)) and assign directly to Shelby Foot and Ankle all insurance benefits; if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all submissions.

The above-named doctor may use my health care information and may disclose such information to the above-named insurance company (ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.

MEDICARE/MEDIGAP AUTHORIZATION
I request that payment of authorized Medicare benefits and, if applicable Medigap benefits, may be made either to me or on my behalf to Shelby Foot and Ankle for any services furnished to me by that provider.

To the extent permitted by law, I authorize any holder of medical or other information about me to release to the Centers for Medicare and Medicaid Services, my Medigap insurer, and their agents any information needed to determine these benefits or benefits or benefits for related services.
Signature of Beneficiary, Guardian or Personal Representative*

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Please Print Name of Beneficiary, Guardian or Personal Representative*
Date*

MonthDayYear
Date
Relationship to Beneficiary*
Family History
Date of Last Physical Exam

MonthDayYear
Date
What is the Reason for This Visit?*
Check an of the illnesses which have occurred in any of your blood relatives*

DiabetesHeart DiseaseCancerStrokeBleeding TendencyHigh Blood PressureKidney DiseaseNervous IllnessTuberculosisAllergyNoneOther
Health History

Please check all that apply. (All information is strictly confidential)
General*

ChillsDepression/NervousnessDizziness/FaintingFeverForgetfulnessHeadacheLoss of SleepLoss of WeightNumbnessSweatsNone
Muscle/Joint/Bone - Pain, Weakness, Numbness in*

ArmsBackFeetHandsHipsLegsNeckHandsShouldersNone
Gastrointestinal*

Chest PainPoor CirculationHigh/Low Blood PressureSwelling of AnklesVaricose VeinsIrregular/Rapid Heart BeatNone
Skin*

Bruise EasilyHivesItching/RashChanges in MolesScarsSores That Won't HealNone
Conditions You Have Had In The Past*

AIDSArthritisAsthmaBleeding DisordersCancerChemical DependencyDiabetesHeart DiseaseHigh CholesterolHIV PositiveKidney DiseaseLiver DiseasePacemakerPneumoniaPolioStrokeUlcersNoneOther
Describe serious illness or surgery(ies)
Medications/Allergies
List all medications you are currently taking*
Pharmacy Name
Pharmacy Phone Number
Please enter a valid phone number.
List allergies to any medications or substances*
Health Habits
Caffeine/Energy Drinks*

01 - 2 per day3-4 per dayOther
Tobacco*

NoneUp to a pack dailyMore than 1 pack daily
Street Drugs*

NoneName Drug and Usage
Check if your work exposed you to*

StressHazardous SubstancesHeavy LiftingNoneOther
Signatures

To the best of my knowledge, the above information is complete and correct. I understand that it is my responsibility to inform my doctor if I, or my minor child, ever has a change in health.
Signature of Patient, Parent, Guardian or Personal Representative*

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Date*

MonthDayYear
Date
Print name of Signature of Patient, Parent, Guardian or Personal Representative*
Relationship to Patient*
Reviewed By
Date

MonthDayYear
Date
Other Questions
Who May We Thank For Referring You*

PatientDoctor's OfficeOther
Patient Referral Name
Doctor's Office Referral Name
Who is your Primary Care Physician?
Primary Care Physician's Address (if known)
Primary Care Physician's Phone (if known)
Please enter a valid phone number.
Who is your Endocrinologist/Diabetic Doctor (if applicable)?
Endocrinologist/Diabetic Doctor's Address (if known)
Endocrinologist/Diabetic Doctor's Phone (if known)
Please enter a valid phone number.
Patient Acknowledgment of Privacy Practices
As the laws regarding patient privacy are changing and new procedures are being put into effect, it is our responsibility to notify you as well as receive feedback from you about how your records will be handled. This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

*PLEASE INITIAL that you have read and understand each statement. If you wish to make changes to a section, please notify the receptionist so that your file is noted properly in our records. Please sign and date the bottom.
initial* I am aware that the Notice of Privacy Practices is available for me to read here in the office, and I may receive a copy upon request.

initial* I am aware that the staff will Identify themselves as a doctor's office when confirming appointments, returning my calls, or for routine follow-up calls. I further understand any message left for me will not include test results or other identifiable medical information.

* I am aware that my podiatrist makes it a practice to keep my primary care and/or specialty physicians notified of my progress by sending a report detailing my initial visit and subsequent visits as needed.

* I authorize the staff of this office to release pertinent information to any physician or provider they refer me to for future care.

* I authorize the following person(s) (for example spouse, family member, friend, bookkeeper) (PLEASE PRINT) First Name* Last Name* to have access to my medical information, including receiving test results, taking advice regarding my condition, making my appointments, and discussing my billing issues. I may change this at any time by signing a new form.
Please note in order to avoid misuse of your protected medical records or information, it is our policy to release the minimum amount necessary, even to those you have agreed may have access.
Signature*

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Patient's Name*
Date*

MonthDayYear
Date
Should be Empty:

Patient Information

Insurance

Insurance Assignment and Release

Family History

Health History

Medications/Allergies

Health Habits

Signatures

Other Questions

Patient Acknowledgment of Privacy Practices