1421 S. Potomac Street, Suite 120 Aurora, CO Please print and complete all parts.
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1 Thomas J. Savage, DPM Jay H. Dworkin, DPM PC 1421 S. Potomac Street, Suite 120 Aurora, CO (fax) Please print and complete all parts. Date PATIENT INFORMATION Name Male Female Address City_ State Zip Apt # Social Security # Home Phone Work Cell Address Date of Birth Age Text message reminders Yes No Single Married Widowed Divorced Referred by Primary Care Physician Pharmacy _ Pharmacy Phone Number Employed Yes No Employer Work Injury Yes No Chief Complaint/ Reason for visit INSURANCE INFORMATION (Please provide insurance cards at time of appointment) Primary Insurance Member ID # Subscriber Name Subscriber Date of Birth Deductible $ Deductible Amount Met $ Copay $ Secondary Insurance Member ID # Subscriber Name Subscriber Date of Birth Assignment of benefits: I authorize payment of medical benefits to Dr. Thomas J. Savage or Dr. Jay H. Dworkin for services provided to me. I authorize the release of any med ical information necessary to process this and all future claims. I understand that I, not the insurance company, am the responsible party for all fees incurred. X Signature Date Dr. Thomas J. Savage DPM and Dr. Jay H. Dworkin DPM, PC, are independent Foot & Ankle Podiatric Physicians sharing the office of Dr. Thomas J. Savage DPM (Metropolitan Foot & Ankle Specialist).
2 MEDICAL INFORMATION DO YOU HAVE ANY OF THE FOLLOWING? (PLEASE WRITE YES OR NO) MEDICAL HISTORY Diabetes Gout Epilepsy Parkinson s Cancer Hepatitis Thyroid Disease Skin Disorder Stomach Ulcers Poor Circulation HIV+ Heart Disease High or Low Blood Pressure Angina Heart Murmur Asthma Emphysema Blood Clots Kidney Disease Neuropathy REVIEW OF SYSTEMS HEART/CIRCULATION Palpitations Chest Pain Leg Swelling Leg Cramps/ Pain when walking Past Heart Attach/ Bypass RESPIRATORY Shortness of Breath Cough or Wheezing Tuberculosis Pulmonary Embolism DIGESTIVE URINARY Frequent Urination Burning Blood in Urine Frequent Urinary Infections Weight gain/loss History of Ulcers Blood in Stool Diarrhea/ Constipation Stomach Pain or Cramps NEUROLOGICAL Headaches Seizures/ Convulsions Tingling/ Burning/ Pain Neuropathy (Loss of Feeling) PHYCHOSOCIAL Anxiety Depression RSD (Reflex Sympathetic Dystrophy) SKIN Itching/ Burning Discoloration New Spots/ Ulcerations/ Wounds EYES/ EARS/ NOSE/ MOUTH Visual Changes Hearing Difficulties Sinus or Mouth Problems MUSCLE/ JOINTS/ BONES Arthritis Osteoporosis BLOOD Bleeding Disorder Anemia
3 SOCIAL Employed Smoke Alcohol Drug U se MEDICATIONS (PLEASE LIST OR PROVIDE A LIST) ALLERGIES (i.e. Aspirin, Penicillin, Codeine, Iodine, Adhesive tape, Latex, Etc.) FAMILY HISTORY (i.e., Diabetes, Heart, Cancer, Foot Problems) PAST SURGICAL HISTORY (List type of surgery, when, and if any complica ons) ANY OTHER INFORMATION YOU THINK WE SHOULD KNOW? THANK YOU FOR TAKING THE TIME TO ACCURATELY COMPLETE THIS INFORMATION!!
4 Thomas J. Savage, DPM Jay H. Dworkin, DPM PC 1421 S. Potomac Street, Suite 120 Aurora, CO (fax) Office Financial Policy and Guidelines FINANCIAL AGREEMENT: 1. Medical services are requested and provided directly to the patient and not the insurance company. 2. Patient is responsible for all co-pays, deductibles, and all non-covered services at the time of service. Including co-pays and deductibles for surgery. 3. Patient is responsible for obtaining any referrals that are required. 4. information, including a copy of the most recent insurance identification card. 5. Secondary insurance will be billed as a courtesy. 6. patient will be responsible for the full balance with NO discounts. 7. If an unpaid balance is sent to a collection agency, I understand and agree that a fee of up to 30% may be added to cover the cost of collection at a collection agency or third party company. OFFICE GUIDELINES: 1. Our office welcomes treatment for all patients, including children. All children under the age of 17 must have a parent of legal guardian present at all appointments. 2. For the safety, comfort, and privacy of our patients and employees, one friend or family member will be permitted to accompany a patient in the treatment room during the appointment. 3. Missed appointments will be charged $50.00 fee for any missed or cancelled appointment without 24-hour advance notice. 4. WE request all cellular phones be turned off or set to silent during your appointment. 5. We reserve the right to dismiss any patient from our practice for any inappropriate behavior in our office or on the phone. I have read the above policies and guidelines and agree with the terms outlines for the office of Dr. Thomas J. Savage DPM and Dr. Jay H. Dworkin DPM, PC.
5 Signature of Responsible Party Date Dr. Thomas J. Savage DPM and Dr. Jay H. Dworkin DPM, PC, are independent Foot & Ankle Podiatric Physicians sharing the office of Dr. Thomas J. Savage DPM (Metropolitan Foot & Ankle Specialist).
Georgia Foot & Ankle
Georgia Foot & Ankle PLEASE PRINT CLEARLY Today s Date / / Name Date of birth / / First MI Last SSN Marital Status M S D W Age Weight Height Male Female Address City State Zip Phone (Home) (Work) (Cell)
MICHAEL J. FRANK, D.P.M., MARC GOLDBERG, D.P.M., ADAM LOWY, D.P.M.
MICHAEL J. FRANK, D.P.M., MARC GOLDBERG, D.P.M., ADAM LOWY, D.P.M. 10801 Lockwood Drive, Suite 260 Silver Spring, Maryland 20901 (301) 439-0300 3408 Olandwood Ct., Suite 204 Olney, Maryland 20832-1367
WELCOME. Date: Patient Name: Social Security #: Address:
WELCOME PATIENT INFORMATION: Date: Patient Name: Social Security #: Address: Email: Sex: Male Female Age: Birthdate: Married Separated Widowed Single Divorced Minor Partnered for years Patient Employer/School:
PATIENT INFORMATION. Patient s Full Name: (First) (Middle) (Last)
PATIENT INFORMATION Patient s Full Name: (First) (Middle) (Last) Birth date: Age: Race: Sex: [ ] Female [ ] Male Marital Status: [ ] Single [ ] Married [ ] Divorced [ ] Widowed SS# Address: City: State:
Name SS# Date of birth / / Gender Ethnicity. Mailing Address City/State ZIP. Marital Status Spouse Name. Phone# Cell# Work#
PATIENT INFORMATION (Please print clearly) Today s date / / Name SS# of birth / / Gender Ethnicity Mailing Address City/State ZIP Marital Status Spouse Name Phone# Cell# Work# EMERGENCY CONTACT PERSON
FOOT & ANKLE SPECIALISTS OF THE TWIN TIERS, PC 455 MAPLE STREET, SUITE 2 BIG FLATS, N.Y PATIENT INFORMATION FORM (PLEASE PRINT) DATE: / /
FOOT & ANKLE SPECIALISTS OF THE TWIN TIERS, PC 455 MAPLE STREET, SUITE 2 BIG FLATS, N.Y. 14814 DATE: / / PATIENT INFORMATION FORM (PLEASE PRINT) PATIENT NAME: LAST FIRST MI DATE OF BIRTH: / / AGE: SEX:
Name: DOB: Chart Number: Spouse/Partner Name: Address: City: State: Zip: Home #: Cell #: Other #: Employer Address: City: State: Zip:
Practice: ADVANCED FOOT & ANKLE INSTITUE OF GEORGIA LLC Today s Date: Name: DOB: Chart Number: Sex: Marital Status: ingle Married Widowed Divorced SS#: E-mail: Spouse/Partner Name: E-mail newsletters,
PATIENT INFORMATION. Last Name: First Name: Middle Initial: Address:
PATIENT INFORMATION Today s Date: Last Name: First Name: Middle Initial: Address: STREET CITY STATE ZIP CODE Gender: Male Female Social Security #: Date of Birth: Home Phone: Cell Phone Work Phone: E-mail:
Chief Complaint Form: Patient Name: Age: DOB: Occupation: Employer: Referring Physician: Town: Primary Care Physician: Town: Y N
Chief Complaint Form: Patient Name: Date: First MI Last Preferred Name Age: DOB: Occupation: Employer: Send Note? Referring Physician: Town: Y N Primary Care Physician: Town: Y N Coach/ Trainer/ Team Doctor:
3 Name: DOB: Chart Number: Sex: M F Marital Status: Single Married Widowed Divorced SS# Employer: Phone: Address:
Practice: Lance Berlin, DPM Today s Date: 3 Name: DOB: Chart Number: Sex: M F Marital Status: Single Married Widowed Divorced SS# E-Mail: Spouse/Partner Name: Address: City: State: Zip: Home #: Cell #:
PODIATRIC REGISTRATION AND HISTORY Dr. Peter F. Gregory, D.P.M.
Dr. Peter F. Gregory, D.P.M. Patient s Name: Date: / / Address: City State Zip Date of Birth: / / Sex: Male Female Home Phone: Cell Phone: Business Phone: Email: (Please check preferred method of contact
o 5801 Allentown Road, Suite 305 Camp Springs, MD 20746
MICHAEL J. FRANK, D.P.M., MARC GOLDBERG, D.P.M., ADAM LOWY, D.P.M. o 10801 Lockwood Dr., Suite 260 Silver Spring, MD 20901 ph. (301) 439-0300 Ix. 681-1488 o 3408 Olandwood Court, Suite 204 Olney, MD 20832
Allergies None Penicillin Sulfa Drugs Codeine Aspirin Tape Latex Iodine-Shellfish. Other allergies: Medications
Today s Date: Height Weight Shoe size (CIRCLE) Allergies None Penicillin Sulfa Drugs Codeine Aspirin Tape Latex Iodine-Shellfish Other allergies: Medications SOCIAL HISTORY (CIRCLE) Do you smoke? No Yes
PATIENT INFORMATION. Patient s Full Name: (First) (Middle) (Last) Birth Date: Age: Race/Ethnicity: Sex: Male Female
Patient s Full Name: (First) (Middle) (Last) Birth Date: Age: Race/Ethnicity: Sex: Male Female Marital Status: Single Married Divorced Widowed SS #: Address: City: State: ZIP: Email: Mobile #: Work #:
If you are employed, please provide the follow information regarding your employer; Employer Name: Work Address:
Personal Information Patient Registration Form Today s Date: Patients First Name: Date of Birth: / / Social Security #: - - Patients Last Name: Sex: Male / Female Marital Status: Married Single Divorced
LERGIES (please list name of medication and what happened when you took it. I d codeine)
NAME DATE OF BIRTH ADDRESS LERGIES (please list name of medication and what happened when you took it. I d codeine) Please complete all of the following questions Have you or any family members ever had
How did you learn about our office? Patient s Last Name: First: MI: Address: City: State: Zip Code: Home Phone: ( ) Cell Phone: ( ) Work Phone: ( )
Date: / / How did you learn about our office? Patient s Last Name: First: MI: Sex: Male Female Date of Birth: / / Age: Address: City: State: Zip Code: Home Phone: ( ) Cell Phone: ( ) Work Phone: ( ) Social
HIPAA Authorization Release Form
HIPAA Authorization Release Form I,, give permission to all my health care and medical services providers and payers to disclose and release my protected health information described below to: Name(s):
PATIENT INFORMATION. DATE OF VISIT: Date of Birth Gender: M F. Address [Apt. # ] City State. address: Employer Phone
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PATIENT INFORMATION DATE OF VISIT: Date of Birth Gender: M F PATIENT FULL NAME: Address [Apt. # ] City State Zip Email address: Preferred Phone: Secondary Phone: Circle: Single Married Partnered Divorced
LEGAL NOTICE/DISCLAIMER The information contained in this document does not establish a standard of care, nor does it constitute legal advice.
LEGAL NOTICE/DISCLAIMER The information contained in this document does not establish a standard of care, nor does it constitute legal advice. The information is for general informational purposes only
ERIC ROCKMORE, DPM, FACFAS
Date: Name Date of Birth Address City State Zip Code Email Address Preferred Language Social Security(Medicaid only) Referred by Gender Race Ethnicity Home# ( ) Work # ( ) Cell ( ) Preferred phone # (
PATIENT INFORMATION DEMOGRAPHICS. First Name Middle Initial Last Name Gender. Mailing address: Apt # City: State: ZIP Code: Home Phone Cell Phone
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Fixing Feet Institute W. Bell Rd., #100 Surprise, AZ Phone: Fax:
We are pleased to Welcome you to our practice. Please take a few minutes to fill out this form as completely as you can. This information will enable our physicians to take better care of your concerns.
General Vital Information
509 Stillwells Corner Road, Ste. E9 Frrehold, NJ 07728 General Vital Information Today s Date: Name: Nickname: Sex: M / F SS #: DOB: E-mail: Address: City: State: Zip: House #: Work #: Cell #: Preferred
PATIENT INFORMATION. PATIENT NAME Last First M.I. Social Security Number. ADDRESS Street DATE OF BIRTH SEX Female Male
PATIENT INFORMATION PATIENT NAME Last First M.I. Social Security Number ADDRESS Street DATE OF BIRTH SEX Female Male City State Zip Home Phone Cell Phone Work Phone EMAIL Marital Status Single Divorced
If patient is under 18 y/o, name of Parent/Guardian: Relationship to Patient: Address: (street) (city/state) (zip code)
At both New Tampa Foot & Ankle AND South Tampa Foot & Ankle, we are committed to getting you back on your feet free of pain and injury so that you can get back to your activities and back into life! We
Please bring the medications you are currently taking. If you had x- rays made, please bring the films with you when you come to the office.
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Bay Area Podiatry Associates, PA
Patient Demographic Information Patient s Name: Date: SS#: DOB: Age: Sex: F M Home Address: Marital Status: Single Married Widow Divorced Separated City: State: Zip: Home Phone: Cell Phone: Work Phone:
If you are prescribed any medications, where would you like the script sent? Pharmacy Name: Pharmacy Phone:
AMELIA A. PARÉ, M.D. PATIENT REGISTRATION Date of visit: PATIENT INFORMATION (PLEASE PRINT) Name: Date of Birth: Age: Male Female Race Social Security #: Marital Status: Single Married Divorced Widowed
PATIENT REGISTRATION FORM Account #:
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OFFICE USE ONLY Date: Photo I.D. Initial Name Date of Birth Address City State Zip Code Email Address Preferred Language Social Security(Medicaid only) Referred by Gender Race Ethnicity Home# ( ) Work
Family Foot and Ankle Centers Patient Registration Form (Please present your insurance cards to the receptionist upon arrival)
Family Foot and Ankle Centers Patient Registration Form (Please present your insurance cards to the receptionist upon arrival) Patient s Name First Last M.I. Nickname Address # City State Zip code Phone:
WOODLAKE PODIATRY, LLC
WOODLAKE PODIATRY, LLC Acct. # (Please fill out completely or mark areas n/a if they do not apply) LAST NAME FIRST NAME MIDDLE INIT. STREET CITY STATE ZIP SSN DOB / / MALE / FEMALE HOME PHONE WORK PHONE
Welcome to Central Florida Foot and Ankle Center
What is the chief complaint for which you came to have treated? Have you ever been to a Podiatrist before? Yes No If yes, please list. Name Last Visit Shoe size: Weight: Height: Is this injury/problem
Colorado Clinics for the Foot and Ankle Dr. Erik Ouderkirk, DPM Dr. Corey Bess, DPM
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Signature: Print Name: Date:
~ PLEASE PRINT CLEARLY ~ LAST ADDRESS FIRST MI HOME PHONE SOCIAL SECURITY # EMPLOYER WORK PHONE DATE OF BIRTH JOB/ PROFESSION: CELL PHONE MARITAL STATUS SPOUSE S SPOUSE S SOCIAL SECURITY # (If under spouse
HIPAA Authorization Release Form
HIPAA Authorization Release Form I,, give permission to all my health care and medical services providers and payers to disclose and release my protected health information described below to: Name(s):
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DRS. NUSSBAUM, LUNDBERG, ALTMAN & PICKETT David N. Nussbaum, DPM, Lori A. Lundberg, DPM Scott Altman, DPM & Scott Pickett, DPM WELCOME TO OUR OFFICE
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Address. City/State/Zip. Marital Status: S M D W Sex: M F Date of Birth / / Age. Primary Phone Secondary Phone. Employer PARENT/GUARDIAN
PATIENT INFORMATION First Name M.I Last Name Address City/State/Zip SSN.#_ Marital Status: S M D W Sex: M F of Birth / / Age Primary Phone Secondary Phone Employer Email PARENT/GUARDIAN Name of Birth /
MICHAEL K. BLOCK, DPM, LLC PATIENT FINANCIAL POLICY
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SILVERDALE EYE PHYSICIANS PATIENT REGISTRATION FORM
SILVERDALE EYE PHYSICIANS PATIENT REGISTRATION FORM DATE REFERRING DOCTOR PATIENT BEING SEEN TODAY NAME: ADULT S EMAIL: DOB: AGE: SEX: F / M HOME PHONE: CELL: APPOINTMENT REMINDERS CIRCLE EITHER HOME PHONE
Name (Last, First, MI): Date of Birth: / /
Name (Last, First, MI): Address: Age: City: State: Zip: Sex: Male / Female Phone #: (Home): (Cell): (Work): Personal Email: Social Security #: Race: Ethnicity: Hispanic/Latino Non-Hispanic/Latino Other
Any pertinent medical records
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Chart # PATIENT INFORMATION Please Print, Complete Fully, And Return To The Front Desk Circle One: Mr. Mrs. Ms. Miss. Dr. Child Please Circle: Sex: Male Female Marital Status: S M Other Widowed Patient
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Fixing Feet Institute W. Bell Rd., #100 Surprise, AZ Phone: Fax:
We are pleased to Welcome you to our practice. Please take a few minutes to fill out this form as completely as you can. This information will enable our physicians to take better care of your concerns.
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Patient Registration Form
Patient Registration Form Name: Last First MI Today s Date: Address: Street City State Zip Phone: Best # Daytime # Cell # Date of Birth: Male Female Occupation: Employer: Social Security #: Email: Spouse
Marco A. Vargas, DPM, FACFAS Alicia E. Johnson, DPM W. Grand Parkway South Suite 530 Sugarland, TX Phone: Fax:
For your convenience, and to simplify the billing process, our practice keeps credit cards securely on file This is done to cover incidental charges, such as copayment, coinsurance, and deductible. Please
SAGUARO SURGICAL PATIENT REGISTRATION FORM
Account # Date Patient Name: M F Last First Legal Nickname MI Is this your legal name? Yes No If no, what is your legal name? Marital Status: SAGUARO SURGICAL PATIENT REGISTRATION FORM Single Married Divorce
IF WE NEED TO CONTACT YOU ASAP FOR SCHEDULE CHANGES, WHAT NUMBER SHOULD
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Email Address Last Name First Name Previous Name Address City State Zip Country Social Security - - Home Phone - - Cell Phone - - Work Phone - - Ext Drivers License State Responsible Party SELF (use info
Welcome To Our Office Please Print
1 PATIENT INFORMATION Date Home Phone ( ) E-mail Street City State Zip Marital Status Children? Ages Occupation May we call you at work? Y N Work Hours SPOUSE/DOMESTIC PARTNER INFORMATION (If appropriate)
TEXT YES VOICE YES PHONE NUMBER PHONE NUMBER
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Date: Patient Health Information. Patient Name: First Middle Last Nickname. Date of Birth: Age: Sex: Male Female. Referring Physician:
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CROSSROADS HEALTH CLINIC Thank you for choosing us as your Health Care Provider.
PATIENT INFORMATION First Name: Middle Initial: Last Name: Mailing Address: Street Address: City: County: State: Zip: Phone #: Work: Ext: Would you like us to text you? Yes No Cell #: Driver s License
NEW PATIENT REGISTRATION
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LAST FIRST MIDDLE ADDRESS: ~ SEASONALADDRESS: ~~~ ~ _
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Patient Information Sheet (Please Print) Name:
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Secondary Insurance Co. Name & Address: Subscriber s Name: Subscriber Soc. Sec. No. Group number:
M a u r i c i o R o n d e r o s, D D S, M S, M P H I. PATIENT INFORMATION: Last Name: First Name: MI: Mr. Mrs. Ms. Male Female Birth date (M/D/Y): Marital status: Dr. Other: Address: City, State: Zip:
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Renaissance Foot & Ankle Center, PC Alan R. Deroy, DPM, FACFAS Aparna Duggirala, DPM, FACFAS REGISTRATION FORM (Please Print) PATIENT INFORMATION 7223-B Hanover Parkway Greenbelt, MD 20770 Ph:(301) 441-2655
CENTER CITY DERMATOLOGY STEPHEN HESS, M.D., Ph.D. MEDICAL HISTORY
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BOSTON ENT ASSOCIATES 560 Hillside Ave, Suite H R. William Mason, M.D Faulkner Hospital Needham, MA 02492 Joshua Kessler, M.D. 1153 Centre St., Suite 52 781-444-4722 Rebecca Stone, M.D. Jamaica Plain,
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Sole Foot and Ankle Specialists 5750 W. Thunderbird Rd Ste F 640 Glendale, AZ Office (602) Fax (602)
Name: Date of Birth: Gender: Male/ Female Preferred Language: List all and circle preferred telephone number: Home Cell: Work: Race (Circle One) White, Black/African-American, Asian, American Indian/Alaskan
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PATIENT INFORMATION DATE NAME PREFERRED NAME: LAST FIRST MI
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Tri State Foot and Ankle Center, LLC Dr. Harold Gruber, DPM Dr. Sandra Hudak, DPM 2018 Naamans Rd. Wilmington, DE 19810 Phone: 302-475-1299 Fax: 302-475-0579 722 Yorklyn Rd. Hockessin, DE 19707 Phone:
Andrea Simons, DPM Davina Cross, DPM Schavey Road, Suite 2, DeWitt, MI (517) Patient History. Name: (First) (MI) (Last)
Today s : Andrea Simons, DPM Davina Cross, DPM 13105 Schavey Road, Suite 2, DeWitt, MI 48820 (517) 668-6166 Patient History of Birth: Social Security #: Name: (First) (MI) (Last) Prefers to be called Address:
Previous Podiatric History Previous Surgical History Height Weight Shoe Size Are You Allergic to Any of the Following?
Associated Podiatrists, P.C. 26750 Providence Parkway Suite 130 - Novi, MI 48374 Telephone: (248)348-5300 PLEASE FILL OUT COMPLETELY Today s date Name (First, Middle, Last): DOB: Home Address: City State
Arizona Center for Aesthetic Plastic Surgery Steven H. Turkeltaub, M.D., P.C. Certified, American Board of Plastic Surgery
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New Patient Medical Information Survey Revised 3/2013
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Foot & Ankle Specialists of Marysville Carly Robbins, DPM Nicklaus Bechtol, DPM 388 Damascus Rd. Marysville, Ohio 43040 Phone: 937-578-4021 Fax: 937-578-4011 Patient Information Last Name: First Name: