• PATIENT INFORMATION

    Kenrick J. Dennis, DPM
  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Gender:*
  • Is your mailing address the same as your home address?
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Race:
  • Ethnicity:
  • Marital Status*
  • Employment Status:
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Insurance Authorization

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Only complete if the patient is not the primary insured:  

  • Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • How many hours per day are you on your feet?
  • Are you allergic to any medications?*
  • please provide details below
  • Current Medications: (Attach a list, if preferred)
  • Have you seen any other doctors about the same problem?
  • Have you ever had foot surgery?
  • Alcohol: Frequency ?
  • Alcohol: Type ?
  • Tobacco Use?*
  • Past history of Tobacco?*

  • Medical History

  • Please check if you have or a family member have had any of the following?*
    Rows

  • 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.

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • REQUEST FOR CONFIDENTIAL COMMUNICATIONS

  • Date of birth
     - -
    2 digit month, 2 digit day, 4 digit year

  • 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 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.

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • May we leave a message?*
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • 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.

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