FLORIDA - Patient Intake Information:
Please Note - The information you provide is encrypted for your safety. This form is H.I.P.P.A compliant.
For Prompt Service Please Complete Our Patient Intake Form
If you have any trouble with this form, Please contact us so we can help: 727-896-4615
Name
*
First Name
Last Name
Date Of Birth
*
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact:
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First Name
Last Name
Emergency Contact Phone:
*
Please enter a valid phone number.
Relationship to Patient:
*
Insurance Information:
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Medicare Part A and B
Medicare Advantage
Tricare
Medicaid
Medicare ID# (Red White and Blue Card ONLY)
*
Do you use any other card at the Doctor's Office?
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Yes
No
If you have Medicare Advantage - Who is your Carrier? (Aetna, Humana, UHC Etc) Please Write NA if you do not have a Medicare Advantage Plan.
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Other Medicare ID (Please write NA if None)
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Medical History
Are you currently receiving Wound Care Treatment?
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Yes
No
Is the wound infected?
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Yes
No
* THIS PERTAINS TO ALL WOUNDS BELOW THE KNEE -- Please describe the Wound Care history: (Wound Vac, Collagen, Surgery Ect)
*
Please specify exactly where the wound is located:
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Doctor's Name and Clinic Location where you have received treatment for the wound. Please write N/A if none.
*
Are you currently living or admitted into a facility?
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Yes
No
Are you currently taking any Blood Thinners?
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Yes
No
Do you use Tobacco?
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Yes
No
Have you every been diagnosed or treated for:
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Diabetes
COPD
Heart Failure
Neuropathy
Kidney Disease or Failure
Liver Disease
None
Have you ever been diagnosed with HIV / AIDS?
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Yes
No
Does a Nurse or Caregiver come to your home?
*
Yes
No
Are you currently receiving Hospice or Palliative Care?
Yes
No
Documents Needed:
Upload Front and Back of Medicare ID Cards
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Upload 2-7 Pictures of the Wound:
*
Browse Files
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Choose a file
Cancel
of
Additional Notes:
I understand the information provided on this form is correct to the best of my ability. Signature
*
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