Intake Form

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Please complete the following form and answer all questions before arriving for your appointment.

Be sure to include your insurance information. We'll see you soon!

Patient Information

First name (*)

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Last name (*)

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Social Security Number

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Your Email Address (Responsible Party) (*)

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Mailing Address (*)

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City (*)

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State (*)

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Zip-Code (*)

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Phone number (*)

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Age (*)

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Date of Birth: Month (*)

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Day (*)

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Year (*)

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Sex (*)

Male Female Invalid Input

Marital Status (*)

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Height (*)

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Weight (*)

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Shoe size (*)

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Race(*)

*This information is requested due to Healthcare Reform laws dictated by Congress.

Ethnicity

Hispanic or Latino Non-Hispanic or Non-Latino Decline to Specify Invalid Input

Preferred Language(*)

English Spanish Other Invalid Input

Specify

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Are you pregnant?(*)

No Yes Invalid Input

Are you nursing?(*)

No Yes Invalid Input

Have you completed an Advance Directive (living will)? (*)

Yes No Invalid Input

Primary Care Physician (*)

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Primary Care Physician Address (*)

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Physician Phone Number (*)

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Date last seen: Month

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Day

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Year

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Pharmacy (*)

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Pharmacy Phone (*)

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Who?

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Other

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Primary Reason for Visit (*)

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Duration of Condition (*)

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What helps / makes it worse?

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Is it limiting your activity level? (*)

Yes No Invalid Input

Secondary problem (if there is one)

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Please list any drug allergies (*)

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List Medications You Take (*)

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Specify other

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If you have cancer, please list type and treatment

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Please list past surgeries and year surgery was performed (*)

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Is your problem related to a Workman’s Comp injury or an auto/other accident?(*)

No Yes Invalid Input

Do you drink alcohol?(*)

Never Past Yes Invalid Input

How often?

Daily 1-2 x Week 1-2 x Month 1-2 x Year Invalid Input

Do you smoke, vape or use chewing tobacco?(*)

Never Past Yes Invalid Input

Please specify

Cigarettes Cigars Chewing Tobacco Vaping Invalid Input

How many per day?

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Method of Quitting

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Do you have/have had a substance abuse problem?(*)

Never Past Yes Invalid Input

Please specify

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Family History

Which family members had the below medical conditions? (father, mother, sibling, etc.)

Diabetes

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Stroke

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Cancer

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Arthritis

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Heart Attack

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HTN

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Insurance Information

Subscriber's Name (*)

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Subscriber's D.O.B. (*)

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Patient's Relation to the Subscriber (*)

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HMO (*)

Yes No Invalid Input

Primary Insurance (*)

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Policy Number (*)

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Policy Holder Name (*)

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Policy Holder Date of Birth: Month (*)

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Day (*)

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Year (*)

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Secondary Insurance

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Secondary Policy Number

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Occupation (*)

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Employer (*)

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Employer Address

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City

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State

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Zip-Code

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Employer Phone Number

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Emergency Contact

First Name (*)

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Last Name (*)

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Relationship to Patient (*)

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Phone (*)

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Responsible Party (if minor patient)

First Name

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Last Name

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Relationship to Patient

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Date of Birth: Month

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Day

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Year

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View Privacy Policy

All office visit charges and co-pays are due at the time services are rendered. It is the patient who is responsible for any and all financial aspects of services rendered. There will be a charge for returned checks, missed appointments without 24 hours notice and completion of any forms. I agree to pay for all deductibles, co-pays, non-covered services and any portion of covered services not paid in full by my insurance plan and understand that such payments are due at the time of service or immediately upon presentation of the bill. I hereby name Advanced Foot & Ankle Medical Center (AFAMC) as my assignee. I instruct my health care benefits plan administrator, i.e. PLAN to pay AFAMC directly for all professional and medical services provided by AFAMC through the means of electronic funds transfer(s) (EFT) or by check(s) made payable to and mailed to AFAMC. I AUTHORIZE THE RELEASE OF ANY MEDICAL INFORMATION NECESSARY TO PROCESS CLAIMS.

I Agree (*) Invalid Input

The above information is correct to the best of my knowledge. I understand that throughout my treatment, I am responsible for notifying the physician and/or medical staff of any and all updates to the information listed above. I also give permission for photographs of my feet to be taken for the possible use with advertising, social media or other internet uses.

I Agree (*) Invalid Input

I acknowledge that I was provided a copy of the Notice of Privacy Practices for Advanced Foot & Ankle Medical Center and I have read (or had the opportunity to read if I so choose) and understood the Notice.

PAYMENT RESPONSIBILITIES

We are pleased to welcome you to our office. New Patients are always appreciated. Our practice has grown as a result of its excellent relationship with our referring doctors and patients. As our patient, please feel free, at any time, to express any concerns or to ask any questions that you may have for the doctor or our staff. In order to assist you in making payment(s) for your podiatric treatment, the following options are listed. Please read them carefully and feel free to discuss them with us.

If you DO NOT have insurance: Payment is due, in full, at the time treatment is provided.

*For your convenience, we accept all major credit/debit cards and cash. We accept personal checks for payments under $50.00.

Medical Records Fee: Advanced Foot and Ankle Medical Center charges a processing and clerical fee of $30.00 for all released medical records and/or x-rays. Upon receipt of payment, these records will be dispensed to you.

If you have Insurance: The percentage of coverage by your insurance company may be based on your insurance company’s own reduced fee schedule for medical services and may be less than actual charges resulting in lower coverage for you. Advanced Foot & Ankle Medical Center has no control over this situation. Lower payment is a direct result of the plan selected by you or your employer. Please be advised that we cannot waive co-payment. We are required by law to collect co-payment.

Commercial Insurance: We will submit your claim to your insurance carrier for you. You are responsible for any deductible or co-payment not covered by your insurance. Once our office has received payment from the insurance company, you will be billed, with 30 day terms, for any amount still owed. You may choose to keep a credit card on file for those balances left to you by your insurance company.

Medicare: This office accepts Medicare assignment. Medicare patients are fully responsible, however, for the initial yearly deductible and the 20% co-insurance. Federal law requires that physicians collect this amount. If you have a secondary insurance to cover the 20%, we will submit the balance to that insurance for payment and you will only be responsible for the yearly deductible.

Please sign with your initials (*)

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Please ensure you have completed all mandatory fields on this form (indicated with an (*) asterisk next to the field) and please wait until our thank you page loads to ensure the form was successfully submitted otherwise your data will be lost.

Patient Information

Social History

Family History

Insurance Information

Emergency Contact

Responsible Party (if minor patient)

Consent for Treatment and Acknowledgement of Policies

PAYMENT RESPONSIBILITIES

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