kdfoot.com-Patient Information

ACKNOWLEDGMENT OF RECEIPT
OF
NOTICE OF PRIVACY PRACTICES
(Please review Notice of Privacy Practices prior to filling in this page)
I acknowledge that I was provided access to a copy of the Notice of Privacy Practices and that I have read (or had the opportunity to read if I so chose) and understood the Notice.
Patient Name*
(please print)
Date

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Parent or Authorized Representative

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(if applicable)
Signature*

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REQUEST FOR CONFIDENTIAL COMMUNICATIONS
Patient Name*
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Date of birth

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I request that any and all communications to me (by telephone, mail or otherwise) by Kenrick J. Dennis, DPM and/or his staff be handled in the following manner:
For written communications, address to:

Same address as on page 1Alternative address:
• For telephone communications: Please list the phone numbers you would like us to use to contact you. Please leave a blank by any # we should not use.
Home
Office
Cell
May we leave a message?*

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Patient Signature*

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Date

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Durable Medical Equipment
Supplies Dispensed in the office:

Many of the items (such as post-operative shoes, orthotic devices, arch supports, braces, bandages, topical medicines) that are dispensed by the doctor in this office are not covered by your insurance. We want you to be informed of this, and make sure you understand that you are responsible for paying for these items when they are received. These items are not returnable.

Please sign below to acknowledge and accept the policy for supply items dispensed in this office.
Patient (or Guardian) Signature*

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Date

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Date
Printed Name
Should be Empty:

	You	An immediate family member (parents/siblings)	N/A
AIDS
Anemia
Arthritis
Asthma
Back Problems
Bleeding Problems
Breathing Problems
Cancer
Chronic Fatigue Syndrome
Diabetes
Epilepsy/Seizures
Eye Problems
Fainting
Foot/leg cramps
Gout
Heart Disease
Hemophilia
Hepatitis
HIV
High Blood Pressure
High Cholesterol
Hyperthyroidism
Hypothyroidism
Kidney Problems
Low Blood Pressure
Parkinson’s Disease
Phlebitis
Rheumatic Fever
Shortness of Breath
Stroke
Swelling
Tuberculosis
Varicose Veins

PATIENT INFORMATION