New Patient Form - Michigan Ave Podiatry Clinic

1
Have you scheduled an appointment yet? (Online or over the phone)
YESNO
2
If you have NOT yet scheduled an appointment, please return to michiganavenuepodiatry.com/appointments and select an appointment time with a doctor before completing this form

-OR-

contact us using one of the following options:

Email us: DPM@MichiganAvenuePodiatry.com

Call/Text us: (312) 701-0770
3
NamePlease write out as displayed on your insurance card (if applicable)
First Name
MI
Last Name
4
Gender
Male
Female
5
Date of Birth
Date of Birth
Month
Day
Year
6
Cell PhoneYou will receive text reminders for your appointments
Area Code
Phone Number
7
Home PhoneIf no home phone, leave blank
Area Code
Phone Number
8
EmailYou will receive text and billing reminders for your appointments
example@example.com
9
Home Address:
Street Address
Street Address Line 2
City
Please Select
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State
Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
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Belgium
Belize
Benin
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Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
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Kiribati
North Korea
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Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
10
What is your shoe size?
11
Who / how were you referred to this office?
12
Would you like us to bill your visit to your health insurance plan?If NO - $200 self-pay is due for a new patient visit, plus any additional procedures/products
YESNO
13
Would you like to upload a photo of your primary card(s) in advance?Completing this step will expedite your visit check-in time-If you have already done so then you can skip this step
YES (easy, secure upload; no manual entry required)NO (you will need to complete this information manually)
14
Primary InsuranceNOTE: We ACCEPT most PPO plans. We do NOT accept HMO plans. We always recommend you call your insurance company to verify in-network status prior to your visit.
Insurance Name
Ins Phone #
ID #
Group # (if present)
Specialist co-pay $
Please Select
Please Select
PPO
HMO (**we do not accept HMO)
Medicare
Other / unsure
PPO or HMO?
15
Primary Insurance (Upload FRONT of card)
Drag and drop files here
Select files to upload
Cancelof
16
Primary Insurance (Upload BACK of card)
Drag and drop files here
Select files to upload
Cancelof
17
Do you have a secondary insurance plan?
YESNO
18
Would you like to upload a photo of your secondary insurance card(s) in advance?Completing this step will expedite your visit check-in time
YES (easy, secure upload; no manual entry required)NO (you will need to complete this information manually)
19
Secondary InsuranceNOTE: We ACCEPT most PPO plans. We do NOT accept HMO plans. We always recommend you call your insurance company to verify in-network status prior to your visit.
Insurance Name
Ins Phone #
ID #
Group # (if present)
Please Select
Please Select
PPO
HMO (**we do not accept HMO)
Other / unsure
Medicare
PPO or HMO?
20
Secondary Insurance (Upload FRONT of card)
Drag and drop files here
Select files to upload
Cancelof
21
Secondary Insurance (Upload BACK of card)
Drag and drop files here
Select files to upload
Cancelof
22
Would you like to upload a photo of your state ID or driver's license in advance?Completing this step will expedite your visit check-in time
YES (easy, secure upload; no manual entry required)NO (you will need to provide your ID for scanning in office)
23
Front of your state ID or driver's license
Drag and drop files here
Select files to upload
Cancelof
24
Pay your co-pay in advance (optional)Pay in advance here -or- we can collect at the time of your visit.
prevnext( X )
Enter your co-pay amount here
USD
Enter your co-pay amount here
First Name
Last Name
25
Preferred PharmacyIf none, choose the pharmacy most convenient to you if an rx needs to be sent.
Street Address
Street Address Line 2
City
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
26
Preferred Language
27
Ethnicity / Race
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or other Pacific Islander
White
Other
28
Emergency Contact and/or Legal Guardian
First Name
Last Name
Relation
Phone Number
29
Do you have a Legal Guardian / Power of Attorney?
YESNO
30
Legal Guardian / Power of Attorney
First Name
Last Name
Relation
Phone Number
31
Do you have a Primary Care Physician?
YESNO
32
Primary Care Doctor - Contact Info
Fax Number
Phone Number
Name
Date of last visit with your doctor
33
Location of PCP / Clinic
Street Address
Street Address Line 2
City
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
34
Date of last visit with PCPYou may estimate
35
Use of alcohol
Never
Rare
Occasional
Moderate
Daily
History of alcohol abuse
36
Have you ever used tobacco?
YESNO
37
Are you currently using tobacco?
YES, I currently use tobaccoNO, I quit using tobacco
38
Tobacco usage (past or present)
How many packs per day? (past or present)
How many years have you used tobacco?
39
Family history
Diabetes
Cancer
Heart Disease
High Blood Pressure
Coronary Artery Disease
Stroke
Rheumatoid Arthritis
Thyroid Disease
Other
40
Do you have any known allergies?
YESNO
41
What are you allergic to? Type "None" if no known allergies.
42
Have you been vaccinated this year for influenza?
YESNO
43
Have you had a pneumococcal vaccination this year?
YESNO
44
Have you ever had any of the following?
Abnormal Bleeding
Acid Reflux
AIDS / HIV Positive
Anemia
Arthritis
Asthma
Back trouble
Bladder infections
Blood clots
Blood transfusions
Cancer
Diabetes
Fibromyalgia
Glaucoma
Gout
Heart attack
Heart disease / failure
Hepatitis
High blood pressure
Immunosuppressed
Kidney disease
Liver disease
Low blood pressure
Migraine headaches
Mitral valve prolapse
Nerve disorder
Neurpoathy
Osteoporosis
Bronchitis / Emphysema
Pneumonia
Polio
Rheumatic fever
Skin disorder
Sleep apnea
Stomach ulcers
Stroke
Thyroid disease
Tuberculosis
Other
45
Have you ever had surgery?
YESNO
46
Please list all past surgeries you've had. Leave blank if none.
Type of surgery
Approx Year
Type of surgery
Approx Year
Type of surgery
Approx Year
Type of surgery
Approx Year
47
Are you currently using any medications?
YESNO
48
Would you like to upload your list of meds or type them out?
Upload file (PDF or DOC)Manually type them
49
Please upload your list of medications here
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
50
Type out your medications here. Please include name, dosage, and dates.
Huge
Large
Normal
Small
Ok
Ok
51
Our doctors are able treat 1-2 separate issues per visit. Additional issues may require a separate appointment. Do you understand and agree to this policy?
YESNO
52
Please describe the 1-2 issue that you would like to address at your appointment
Issue 1: What specific problem brought you in?
When did the issue start?
Is the injury work related?
Issue 2 (optional): What specific problem brought you in?
When did the issue start?
Is the injury work related?
53
Please provide your current place of work and describe your current job/occupation
54
How would you rate your pain on a scale of 0 to 10?0 being no pain, 10 being the worst pain
55
Describe your pain
Dull
Sharp
Burning
Throbbing
Shooting
Numbness
Other
56
Click next after reading
57
Do you understand and agree to each of the policies & practices listed on the previous page?
YESNO
58
Do you attest to the accuracy of all information entered by you in this form?
YESNO
59
By signing, you are agreeing to the policies outlined in this form, and are attesting to the accuracy of all information entered.In order to sign on a PC, hold down the left mouse button and "write" your signature below
Clear
60
By signing, you are agreeing to the policies outlined in this form, and are attesting to the accuracy of all information entered.In order to sign on a PC, hold down the left mouse button and "write" your signature below
Clear
61
Click review & submit below.

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If you already selected your appointment time, then you are all set!

If you still need to schedule a time,

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send us a text message to (312) 701-0770 use the “Contact Us” link below,

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