This secure form consists of 3 parts and will take approximately 5 minutes to complete. You are on a secure website, however if you prefer you can complete this form, print it, and bring it along with you.

We do NOT require your Social Security Number on this form.

 

1 -  PATIENT INFORMATION:
First Name
Last Name
Address
City
State
Zip Code
Data of Birth e.g. 01/01/1960
Home Phone e.g. 999-555-1212
Marital Status Married SingleWidowedMinor Separated Divorced Partnered
Sex Male Female
Employer/ School
Employer/School Phone e.g. 999-555-1212
In case of emergency
contact Name & address
2 -  INSURANCE:
Who is the primary on this account? Self     Other, Please specify
Data of birth of the primary. e.g. 01/01/1960
Relationship to patient Self Other, Please specify
Insurance Company
Group Number
Subscriber ID
Insurance Phone Number e.g. 999-555-1212
Is patient covered by other insurance? NO (please skip the section below)
YES  (Please bring information on your secondary insurance)

INSURANCE ASSIGNMENT AND RELEASE

I certify that I have insurance coverage with the above insurance company and assign directly to All-in-One Foot Care Center 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. I authorize the use of my acceptance on all insurance submissions.

All-in-One Foot Care Center may use my health care information and may disclose such information to the above-named insurance company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the submission date of this form.

I Agree (Beneficiary, Guardian or Personal Representative)
Name
Relationship to beneficiary
 
3 -  PODIATRIC AND MEDICAL HISTORY:
Main reason for visiting us:
e.g. foot, ankle, knee, etc.
Have you been to a Podiatrist(s) before No YES - Please list name(s) 
Cigarette / Tobacco use No YES - Please specify years smoked
Is there any personal or family history of diabetes? No YES

Please indicate which foot problems you now have or have had in the past.

Ankle Pain YESNo Flat Feet YES,No
Athlete's Foot YESNo Foot or Leg Cramps YES,No
Bunions YESNo Heel Pain YES,No
Corns & Calluses YESNo Ingrown Toenails YES,No
Cramps or Numbness in Feet or Legs YESNo Plantar Warts YES,No

Please choose "YES" or "NO" to indicate if you have had any of the followings:

AIDS/HIV YESNo Hepatitis or Jaundice YESNo
Allergies to Anesthetics YESNo High Blood Pressure YESNo
Allergies to Medicine or Drugs YESNo Kidney Problems YESNo
Anemia YESNo Liver Disease YESNo
Angina YESNo Low Blood Pressure YESNo
Arthritis YESNo Neuropathy YESNo
Artificial Heart Valves or Joints YESNo Phlebitis YESNo
Asthma YESNo Psychiatric Care YESNo
Back Problems YESNo Radiation Treatment YESNo
Bleeding Disorders YESNo Rash YESNo
Cancer YESNo Respiratory Disease YESNo
Chemical Dependency YESNo Rheumatic Fever YESNo
Chest Pain YESNo Shortness of Breath YESNo
Chronic Diarrhea YESNo Sinus Problems YESNo
Circulatory Problems YESNo Special  Diet YESNo
Diabetes YESNo Stroke YESNo
Ear Problems YESNo Swelling in Ankles, Feet YESNo
Epilepsy YESNo Swollen Neck Glands YESNo
Eye Problems YESNo Tired Feet YESNo
Fainting YESNo Tuberculosis YESNo
Gout YESNo Ulcers YESNo
Headaches YESNo Varicose Veins YESNo
Heart Disease YESNo Venereal Disease YESNo
Hemophilia YESNo Weight Loss, Unexplained YESNo
       

Surgeries you have had:

Hospitalization other than for the surgeries listed:

Family physician Name
& last date visited:

Are you now, or have you been, under any other doctor's care for any reason over the past two years? YESNO

If yes, please explain->

Medications?
Include prescriptions, over-the-counter medications and vitamins:

Pharmacy Name(s):

Pharmacy Phone(s):

Do you take oral contraceptives:

YES NO    
ALLERGIES
Adhesive/Tape Local Anesthetics
Anticoagulant Therapy Novocaine
Aspirin Penicillin
Codeine Seafoods
Demerol Sulfa
Iodine    
Other Please explain -->
       
TREATMENT CONSENT
I hereby consent and give my permission to the doctor (and the doctor's assistants or designated replacement) to administer and perform such procedures upon me as the doctor seems necessary.