• Image field 1

  • PATIENT INFORMATION

  • Date:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Preferred Method Of Contact (please check box)
  • Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Gender

  • INSURANCE INFORMATION

    PRIMARY INSURANCE

  • SECONDARY INSURANCE

  • Primary Care Physician (PCP)

  • Format: (000) 000-0000.
  • Date last Seen:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Marital Status:
  • Primary language:
  • Race:
  • ETHNICITY:

  • PATIENTS UNDER 18

  • RESPONSABLE PARTY

  • RESPONSABLE PARTY Selection
  • Date of Birth:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Emergency Contact

  • Format: (000) 000-0000.

  • Pharmacy Information

  • Format: (000) 000-0000.

  • PATIENT MEDICAL INFORMATION

  • DATE:
     - -
    2 digit month, 2 digit day, 4 digit year
  • DATE LAST SEEN BY PRIMARY CARE PROVIDER:
     - -
    2 digit month, 2 digit day, 4 digit year

  • ALLERGIES

  • ALLERGIES

  • MEDICATIONS (INCLUDING OVER-THE-COUNTER MEDICATIONS AND VITAMINS)

  • PODIATRY HISTORY

  • PODIATRY HISTORY
  • SMOKING STATUS?
  • SMOKER
  • *Vaping*
  • * TOBACCO USE*
  • *DRUG USE*
  • DO YOU DRINK ALCOHOL?
  • CAFFEINE USAGE?

  • GENERAL MEDICAL HISTORY

  • GENERAL MEDICAL HISTORY

  • CONSENT TO TREAT

  • I, the undersigned consent to any initial or follow-up evaluations, examinations, x-rays, laboratory procedures,other tests, medications, medical treatment, surgery, physical therapy, home instructions, orthotics, otherdurable medical equipment, Photographing and/or video recording, and/or other services rendered to thepatient by The Foot Center Inc. and its providers.

    FINANCIAL POLICY FOR THE FOOT CENTER INC.

    • Payment In full is due at time of service unless prior arrangements have been made.
    • Any and all co-payments are due prior to any services being rendered. Until co-payments are received,the physician will not see patients
    • If we are a participating provider with your primary health insurance, we are happy to file a claim on ourbehalf. However, once the insurance company is billed we allow 60 days for the balance to be paid byyour insurance carrier. If the insurance carrier does not remit payment within 60 days, the balance willbe due in full from you.
    • HMO/PPO claim denials due to no referral or authorization are the patient's responsibility. Office staffwill notify and assist you in referral / pre-certification procedures, but final responsibility lies with thepatient to comply with their specific insurance's requirements. All referrals must be presented to ouroffice prior to seeing the doctor.
    • There is a $75.00 charge for all returned checks.
    • Please be on time for your appointment. If you need to reschedule your appointment, please call ouroffice 24 hours In advance. There will be a $100.00 charge for appointments missed without a 24 hournotice.
    • If your account must be forwarded to a collection agency and or an attorney because of non-payment,you will be responsible for all collection fees and/or attorney's fees as well as costs associated withthese services.

    ASSIGNMENT OF BENEFITS

    I, the undersigned do hereby certify that I (or my dependent) have coverage with insurance given and doassign directly to The Foot Center Inc all insurance benefits, payable to me for the services rendered. I alsounderstand that I am responsible for payment of any and all deductibles, co-payments, and/or for any othernon-covered services. I so hereby authorize The Foot Center Inc to release all information necessary to securepayment of benefits. I authorize release of medical information to my insurance carrier, or requested physicianto provide continuity of care. I authorize the use of this signature on all insurance submissions.

    • By my signature below I acknowledge receipt of a copy of this assignment of benefits policyand hereby agree to its terms.
    • I acknowledge receiving The Foot Center Inc's Notice of Privacy Practices (posted in the officeor requested copy).
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • I authorize the following individual to receive information on my behalf. This includes medical information.

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: