New Patient Form in Acton, MA | Acton Foot And Ankle LLC

Name

First Middle Last

Date

Age

Male
Female

Height

Weight

Shoe Size

Do you have children?

Yes
No

ages

Address

Street Address PO Mailing Address(if applicable) City State / Province / Region ZIP / Postal Code

Home Phone

Cell Phone

Work Phone

Occupation

Retired?

Yes
No

Email Address(please Print clearly)

Marital Status:

Single
Committed relationship
Married
Widowed
Separated
Divorced

Spouse/Partner Name

Date of Birth

Is patient a minor? Name of parent or guardian

Address of parent or guardian, if different

Street Address City State / Province / Region ZIP / Postal Code

Home Phone

Cell Phone

Work Phone

Best Contact Information

Home Phone

Cell Phone

Work Phone

Emergency Contact

Cell Phone

Relationship

Payment And Insurance Information

Check here if no health insurance

Full Name of Insured

Relationship to Patient

Insured Date of Birth

Insured Employer

Employer Address

According to my insurance, I am required to pay a co-payment amount $

Deductible amount$

We require co-payment at time of service. We accept-cash, checks, Visa, Mastercard, and Discover.

My insurance requires a referral from my primary care physician before I see a specialist:

Yes
No

Referral Information

We appreciate referrals! Whom may we thank for referring you to our office?

Name

Address

Is this person your:

Primary Care Physician
Other Specialist
Family Member
Friend

Is this person your:

Internet Search
Our Website
Phone Book
Saw Our Sign

Newspaper ad, which paper?

Insurance plan or website?

Other (tell us more)!

PODIATRIC HISTORY

Have you ever been to a podiatrist before?

Yes
No

What is the chief foot complaint for which you came to be treated?

When did it begin?

Did you receive treatment for this condition?

Yes
No

If so, what type?

Circle the degree of pain you are currently experiencing:

Have you ever had any of the following foot conditions?

Have you ever been treated for any of the following conditions? Please v all that apply to you, put an M if on your mother's side and a P if on your father's.

MEDICATION

Are you currently on blood thinners?

Yes
No

You can provide a printout of your medications or list them below:

Medicine name	Strength/mg	How often?

Do you currently use cigarettes or tobacco?

Yes
No

If yes, how long?

If quit, how long?

Yrs

If quit, how long?

Alcohol use?

Yes
No

If yes, quantity

Daily

Monthly

SURGERIES

Please list all surgeries / Approximate date

Name of MD/family physician

Address

Street Address

Date of last visit

ALLERGIES

Have you ever had any adverse effects or an allergy to:

Adhesive tape

Yes
No

Anticoagulants

Yes
No

Aspirin

Yes
No

Codeine

Yes
No

Cortisone

Yes
No

Iodine

Yes
No

Latex

Yes
No

Metal/jewelry

Yes
No

Novocaine

Yes
No

NSAIDs

Yes
No

Peanuts

Yes
No

Penicillin

Yes
No

Seafood

Yes
No

Seafood

Yes
No

Antibiotics

Yes
No

Pain medication

Yes
No

Other

Yes
No

If other, please explain:

SIGNATURE OF FILE AND PERMISSION TO TREAT

• I understand that the information provided on this form is true and correct to the best of my knowledge.
• I request that payments of authorized benefits be made on my behalf for any services furnished by Acton Foot and Ankle.
• I authorize any holder of information about me to release any information needed to determine these benefits or the benefits payable to related services to the insurance agent.
• I recognize my financial obligation of an co-insurance, co-payments, or deductibles and non-covered services that may be required.
• I hereby give permission to Acton Foot and Ankle and any qualified staff to evaluate, diagnose and treat my foot and/or ankle condition as may be deemed necessary

Patient or authorized signature:

If not patient, state relationship:

Date