New Patient Registration - Complete Online Form

  • Advanced Foot Care Center

    David M. Velarde, DPM | 2824 Merchant Dr. Knoxville, TN 37912 | 865-523-1141
    Fax: 865-521-6635 | www.knoxvillefootdoctor.com

  • New Patient Registration - Complete Online Form

  • Patient Demographics & Contact Information

  • PATIENT INFORMATION

  • TODAY'S DATE*
     - -
  • DATE OF BIRTH*
     - -
  • SEX*
  • MARITAL STATUS
  • SPOUSE DOB
     - -
  • Format: (000) 000-0000.
  • IS PATIENT BEING SEEN AT A PAIN CLINIC?

  • CONTACT INFORMATION

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • PREFERRED PHONE
  • OK TO LEAVE DETAILED MESSAGE?
  • WOULD YOU LIKE TO RECEIVE TEXTS?
  • PREFERRED CONTACT METHOD

  • EMERGENCY CONTACT

  • Format: (000) 000-0000.

  • EMPLOYMENT

  • EMPLOYMENT STATUS
  • Format: (000) 000-0000.
  • PRIMARILY SIT OR STAND AT WORK?

  • FOR PATIENTS UNDER 18

  • DATE OF BIRTH
     - -
  • Format: (000) 000-0000.
  • HEALTH SCREENING - CHECK ALL THAT APPLY
  • WHICH FOOT IS BOTHERING YOU?*
  • FREQUENCY OF PAIN
  • AREA(S) AFFECTED — CHECK ALL THAT APPLY
  • HOW LONG HAS IT BEEN BOTHERING YOU?
  • TRIED ANYTHING TO TREAT IT?
  • SEEN ANOTHER PHYSICIAN FOR THIS?

  • MEDICATIONS

  • MEDICATIONS OPTIONS
  • Rows

  • ALLERGIES

  • ALLERGIES LIST

  • OTHER ALLERGIES

  • LOCAL PHARMACY

  • Format: (000) 000-0000.

  • SURGICAL HISTORY

  • PRIMARY CARE PHYSICIAN

  • Format: (000) 000-0000.

  • Medical & Podiatric History

  • MEDICAL HISTORY - CHECK ALL THAT APPLY

  • OTHER MEDICAL CONDITIONS

  • B PODIATRIC HISTORY – CHECK ALL THAT APPLY

  • OTHER PODIATRIC HISTORY

  • REPRODUCTIVE & SPECIAL NEEDS

  • REPRODUCTIVE STATUS
  • REPRODUCTIVE STATUS
  • SPECIAL NEEDS – CHECK ALL THAT APPLY

  • FAMILY HISTORY

  • Rows

  • SOCIAL HISTORY

  • DO YOU SMOKE CIGARETTES?
  • DO YOU VAPE NICOTINE?
  • DO YOU DRINK ALCOHOL?
  • DO YOU USE RECREATIONAL DRUGS?
  • DO YOU EXERCISE REGULARLY?

  • Insurance & Assignment of Benefits

  • PRIMARY INSURANCE

  • POLICY HOLDER DOB
     - -
  • RELATIONSHIP TO PATIENT
  • Format: (000) 000-0000.

  • SECONDARY INSURANCE (IF APPLICABLE)

  • RELATIONSHIP TO PATIENT

  • BASSIGNMENT OF BENEFITS

  • I, the undersigned, certify that I (or my dependent) have the insurance coverage listed above and assign directly to Advanced Foot Care Center and/or David M. Velarde, DPM 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, including co-pays, deductibles, and/or co-insurance. I hereby authorize the release of all information necessary to secure payment of benefits and authorize use of this signature on all insurance submissions.
  • DATE **
     - -

  • FOR MEDICARE PATIENTS ONLY

  • I request payment of authorized Medicare benefits be made either to me or on my behalf to Advanced Foot Care Center and/or David M. Velarde, DPM for services furnished. I authorize any holder of medical information about me to release to the Health Financing Administration and its agents any information needed to determine these benefits. In Medicare assigned cases, the physician agrees to accept the charge determination of the Medicare carrier as the full charge, and the patient is responsible only for the deductible, coinsurance, and any non-covered services.
  • ARE YOU A MEDICARE PATIENT?
  • DATE
     - -

  • Privacy & HIPAA Consent

  • A NOTICE OF PRIVACY PRACTICES

  • Your Privacy Rights

  • Advanced Foot Care Center is committed to protecting the privacy of your personal health information (PHI). We respect the privacy of your personal medical records and will do all we can to secure and protect that privacy. We strive to always take reasonable precautions to protect your privacy and provide the minimum necessary information to only those who need it for your care.

  • How We Use Your Information

  • We may use and disclose your health information for treatment, payment, and healthcare operations. We may have indirect treatment relationships with laboratories and other providers and may need to disclose PHI for treatment or payment purposes. We will not sell your personal health information to third parties.

  • Your Rights

  • You have the right to receive a copy of our Notice of Privacy Practices, to request restrictions on how we use your PHI, and to revoke your consent in writing at any time. You may not revoke actions already taken that relied on a previously signed consent. If you have any objections, please ask to speak with our HIPAA Compliance Officer.

  • Our Commitment

  • All employees, managers, and physicians undergo ongoing HIPAA training. We have implemented a Compliance Program to prevent any inappropriate use or disclosure of PHI. We welcome your feedback to help us protect your privacy and improve our services.

  • AUTHORIZATION TO DISCLOSE INFORMATION

  • I authorize Advanced Foot Care Center to disclose my personal health information to the following individual(s):
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • AUTHORIZED COMMUNICATION METHODS

  • Advanced Foot Care Center is authorized to leave messages via:
  • Advanced Foot Care Center is authorized to leave messages via:

  • PATIENT CONSENT & SIGNATURE

  • I certify that the above information is true and correct to the best of my knowledge. I give my permission to Dr. David Velarde to administer and perform the procedures he deems necessary in the diagnosis and/or treatment. I understand that perfect results cannot be guaranteed. By submitting this form I acknowledge receipt of the Notice of Privacy Practices.
  • DATE **
     - -
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