• Patient Information

  • Birthdate
     - -
  • Sex
  • Marital Status
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • If Student:
  • Race (You can check more than one)
  • Ethnicity:
  • Language
  • Format: (000) 000-0000.
  • DOB
     - -
  • Format: (000) 000-0000.

  • Disclosure Regarding Solicitation of Patients
    (as required by section 102 of the Texas Occupational Code)

    Texas law requires that at the time of initial contact and at the time of referral, Texas Physicians disclose to patients (i) any affiliation the physician has with a person or healthcare facility for whom the patient is secured or solicited, and (ii) that the physician may receive, directly or indirectly, re-numeration for securing or soliciting the patients. This disclosure is intended to help you make a fully informed decision about your healthcare. Mark A. Barinque, DPM has direct or indirect ownership with Lubbock Heart and Surgical Hospital and may receive re-numeration from the listed healthcare facility. Please let our staff know if you have any questions. Thank you.

  • Reason for Visit

  • Date:
     - -
  • Have you had this problem before?
  • Did you injure or traumatize your foot?
  • Has the problem
  • Have you been treated by another physician for this problem?

  • Patient Health History

  • DOB:
     - -
  • Date:
     - -
  • Past Medical History: Please check all that apply to you:

  • Social History:

  • Do you drink alcohol?
  • Do you smoke?
  • Do you consume caffeine?
  • Do you use recreation drugs?
  • Are you on a special diet?

  • Family History:

  • Do you know of any blood relative who has or had:
  • General Health
  • Allergy
  • Ears, Nose, Mouth, Throat
  • Eyes
  • Gastrointestinal
  • Neurological
  • Genitourinary
  • Heart and Lungs
  • Muscles/Joints/Bones
  • Psychiatric
  • Pulmonary
  • Skin

  • ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY NOTICE

  • I acknowledge that I was provided a copy of the Notice of Privacy Practices and I read (or had the opportunity to read) and understand the notice.

  • Date
     - -

  • PAYMENT OF BENEFITS AND TERMS

    I understand that Dr. Mark A. Barinque (Podiatric Medical Partners of Texas (PMPT) will bill my insurance company and I have provided adequate information. I authorize the release of medical information necessary to process the claim for medical benefits by my insurance company directly to Dr. Mark A. Barinque (PMPT). I acknowledge that I am responsible for all charges incurred and understand insurance co-payments are due at the time of service. If the co-pay cannot be paid at the time of service we may need to reschedule your appointment. I understand and agree to the above terms and information of Dr. Mark A. Barinque (PMPT)

  • Date
     - -
  • Date
     - -
  • Should be Empty: