Basso Foot and Ankle Clinics
Welcome to our practice! Please complete the following intake form.
Name
First Name
Last Name
Birth Date
-
Month
-
Day
Year
Date
Gender
Female
Male
Email
example@example.com
Preferred Phone Number
Format: (000) 000-0000.
Alternate Phone Number
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Photo ID (Front)
Insurance Provider
Insurance Card (Front)
Insurance Card (Back)
Emergency Contact Information
Medical History
Please Check all that apply
What is your HgbA1c?
Please Check all that apply
Primary Care Physician
Preferred Pharmacy
List all current medications
Allergies
Prior surgeries
Weight
Height
Average # alcoholic drinks per week?
Smoking habits
None
0 -1 package a day
1 - 2 packages a day
2+ packages a day
How did you hear about us?
Date
-
Month
-
Day
Year
Date
Signature
Submit
Submit
Should be Empty: