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- Rolf Washington
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1 Histry and Physical Name: Height: Weight: She Size: OFFICE USE: BP= / PULSE= List f Current Medicatins: Allergies: Medical Histry: Allergies Anemia Anxiety Arthritis Asthma Back Pain Bld Clts Bleeding Prblems Breathing Prblems Cancer (type) Circulatin Depressin Diabetes Emphysema Fibrmyalgia Prblems Type 1 Type 2 Gut Heart Disease Heart Murmur Hepatitis High Chlesterl High Bld HIV IBS Kidney Disease Liver Disease Pressure Mental Illness Neurpathy Psriatic Arthritis Rheumatid Arthritis Restless Leg Syndrme Sleep Apnea Skin Disrders Strke Other (specify) Are Yu Pregnant? Yes N Are Yu Nursing? Yes N Surgical Histry: Adenids Angiplasty Appendix Cataracts Clnscpy C-Sectin Gallbladder Heart Bypass Heart Stent Hip Replacement Teeth Tnsils Tumr Remval Other: Have yu ever had any surgical prcedure n yur ft/ankle? Yes N If yes, please describe: D yu have any artificial jints? N Yes, Where?_ D yu have an artificial heart valve? N Yes
2 Family Histry: Is there any family histry f the fllwing? Please specify whether it is yur mther, father, r ther family member. Arthritis Asthma Bleeding Bld Clt Cancer Prblems Diabetes Type 1 Type 2 High Bld Pressure Heart Disease Kidney Disease Liver Disease Other (specify) Scial Histry: D yu drink alchl? N Rarely Scially Everyday D yu drink caffeinated beverages? N Yes, Hw much? What is yur ccupatin? D yu exercise regularly? N, I d nt. Yes, I d the fllwing regular exercise: Substance Abuse: N Yes, I have a current substance abuse prblem. D yu smke? N Yes Frmer Please specify: If yes, hw many packs per day? ½ Hw lng? Review f Systems: (Please check the bx if yu currently have any f these symptms r check ) Cardivascular Ankle Swelling Cld Feet/Hands Leg Pain Leg Swelling Palpitatins Vascular Disease Gastrintestinal Abdminal Pain Bld in Stl Cnstipatin Decreased Appetite Diarrhea Heartburn Vmiting Ulcers Geniturinary Bld in Urine Decreased Urinatin Excessive Urinatin Kidney Stnes Incntinence Painful Urinatin Integumentary Athletes Ft Callus/Crns Cracked Heels Ingrwn Tenail Kelids Nail Changes Nail Fungus Ulcers Warts Musculskeletal Ankle Pain Arch Pain Ball Pain Neurlgical Numbness Paralysis Respiratry Chest Pain COPD Bttm f Ft Pain Flat Feet Seizures Tingling/Burning Cughing Shrtness f Breath Heel Pain Te Pain Tp f Ft Pain Tremrs Weakness Wheezing
3 What is the reasn fr yur visit tday? On a scale f 1-10, hw wuld yu rate yur pain ( 1 being n pain t 10 being the wrst ): Hw lng has this bthered yu? What treatments have yu tried and have they been effective? The pain quality is: burning cnstant dull sharp shting thrbbing tingling tearing Other: What make the pain wrse? Running Walking Standing Certain Shes Elevatin Tuching/Rubbing Other: Have yu experienced any trauma r injury t the area? Is this cnditin the result f an event at wrk? N Yes If yes, have yu ntified yur emplyer and the wrker s cmpensatin liaisn at yur place f emplyment? What is their cntact infrmatin? Please circle where n yur feet/ankles yu are having pain. RIGHT FOOT LEFT FOOT RIGHT FOOT LEFT FOOT LEFT FOOT RIGHT FOOT PLEASE READ AND SIGN The abve infrmatin is crrect t the best f my knwledge. I understand that thrughut my treatment, I am respnsible fr ntifying the physician and/r medical staff f any and all updates t the infrmatin listed abve. Patient Signature: Date:
4 Patient Infrmatin Date: SSN:_ Birth Date: Name: Last Name First Name Initial Address: City: State: Zip: Hme #: Cell #: Sex: M F Minr Single Married Divrced Widwed Separated Emplyer: Business Phne: Emergency Cntact: Phne #: Wh is yur Primary Care Dctr? Date last seen? Wh may we thank fr referring yu? Hw did yu hear abut Feet First Pdiatry? Insured Infrmatin Primary Insurance: Subscriber Name: Sex: Male Female Subscriber DOB: Subscriber SSN: Relatinship t insured: Spuse Child Self Other Phne #: Address: Plicy ID: Grup ID: Secndary Insurance: Subscriber Name: _ Subscriber DOB: Subscriber SSN: Relatinship t insured: Spuse Child Self Other Phne #: Address: Plicy ID: Grup ID: I hereby authrize payment directly t Feet First Pdiatry f all insurance benefits therwise payable t me fr services rendered. I understand that I am financially respnsible fr all charges, whether r nt paid by insurance, and fr all services rendered n my behalf r my dependents. I understand that I am financially respnsible fr any cllectin fee shuld I default n any patient balances. I authrize the abve dctr and/r prvider r supplier f services in this ffice t release the infrmatin required t secure the payment r benefits. I authrize the use f this signature n all insurance submissins. Signature f Respnsible Party: Date:
5 LATE TO APPOINTMENT POLICY If yu are an established patient and yu arrive 15 minutes late r mre t yur appintment yu will likely be asked t reschedule unless the physician s schedule can still accmmdate yu. Pririty will be given t the patients wh arrive n time and yu may have t be wrked in between them. This may mean yu will have a cnsiderable wait. If this is nt cnvenient fr yu, yu may chse t reschedule. One r tw late patients cause the entire daily schedule t fall behind. This is an incnvenience t everyne including the patients. We strive t see every patient as clse t their appintment time as pssible. Likewise if yu are a new patient and yu arrive at the scheduled appintment time and nt early t cmplete yur frms as instructed and it takes mre than 15 minutes t cmplete the frms and the registratin prcess, yu may als be asked t reschedule. We ask that yu please be curteus f yur prvider s valuable time and attentin. The physicians, ffice staff, as well as yur fellw patients will thank yu. ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES I acknwledge that I was prvided with a cpy f the Ntice f Privacy Practices and that I have read (r had the pprtunity t read if I s chse) and understd the Ntice. Patient Name (please print) Parent r Authrized Representative (If Applicable) Signature Date
6 Financial Plicies Feet First Pdiatry The physicians and staff f Feet First Pdiatry want yu t cmpletely understand ur financial plicies. Payment f Services Payment fr services rendered is ultimately the patient's respnsibility. Yur insurance plicy is a cntract between yu and yur insurance cmpany. It is YOUR respnsibility t give us crrect infrmatin abut yur insurance cmpany. Yu must cmply with the rules f yur insurance cmpany such as btaining a valid referral frm. Plan eligibility fr prcedures des nt always cnfirm certificatin, authrizatin r payment f service. We will file yur insurance claim, but fr claimed denied because f failure t cmply with the insurance cmpany requirements, yu will be respnsible fr paying the denied amunt. Fr patient balances and self-pay accunts, we accept cash, Visa, Discver and MasterCard. In the event f nn-payment, yu will be respnsible fr any cllectin and/r legal fees assciated with the cllectin f the balance due. C-Payments and Deductibles Yur insurance cmpany requires yu t pay yur c-pay at the time f the service. Failure t pay is a vilatin f yur cntract with yur insurance cmpany. Please d nt ask us t bill yu fr a c-pay. If yu d nt have yur c-pay with yu, we are happy t reschedule yur appintment at the next available pening. The deductible amunts are always the patient respnsibility. Until the deductible amunt is satisfied, yur insurance is nt respnsible fr reimbursement r payment. Nn Cvered Services Nt all insurance plans cver all services. In the event yur insurance plan determines a service t be "nt cvered", yu will be respnsible fr the cmplete charge. We recgnize gvernment plans require an "Advance Beneficiary Ntice" which we will prvide. Wrkers' Cmpensatin Claims We file wrkers cmpensatin claims, hwever: - Yur emplyer must apprve treatment and the bill fr services rendered must be sent t yur emplyer r their Wrkers' Cmpensatin carrier. - If yur emplyer des nt apprve treatment and YOU SELECT US FOR TREATMENT, yu will be respnsible fr the bill. Lawsuits and Third Party Billing We d nt accept third party billing. Yu are respnsible fr payment f ur regular fees at the time f service unless ther arrangements are made in advance with ur financial crdinatr. N Insurance Cverage If yu d nt have insurance cverage, we expect payment in full befre service is rendered. In certain circumstances, payment plans may be made in advance f yur visit. If yu default n yur prmised payment, ur plicy is t refer yur accunt t a cllectin agency. Physician Nn Participatin in Yur Insurance Plan We participate in numerus insurance plans. Hwever, there are plans with which we d nt participate and therefre yu wuld be respnsible fr the difference between the "Out f Netwrk" payment and ur billed charges. If yu have questins, please cntact yur insurance plan. I have read and understand and practice's financial plicy and I agree t be bund by its terms. Signature f patient (r respnsible party) Date
PATIENT FORM. Abtin Tabaee, MD. Reviewed By: Referring MD Primary Care MD Same Pharmacy Preference Name: Name: Name: Phone: Phone: Phone:
PATIENT FORM Patient Name: Date f Birth: High bld pressure Diabetes Heart disease Strke Asthma Other: Past Medical Histry COPD Thyrid disease Seizures Anxiety Depressin Medicatins (Name, dsage) Referring
STOUGHTON DENTISTRY PATIENT INFORMATION INSURANCE INFORMATION ADDITIONAL INSURANCE INFORMATION
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Main Phone #: ( ) - Secondary Phone # :( ) -
Patient Infrmatin Email: Male r Female: SS# - - DOB: / / Address: Main Phne #: ( ) - Secndary Phne # :( ) - (Circle One): Married Single Divrced Widwed Name f Spuse r Guardian: In Case f Emergency: Whm
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