New Patient Form

In order to provide the best level of care, this form must be completed in its entirety. Doing so will also reduce your appointment wait time. If something does not apply, please notate "N/A or Not Applicable"

Patient Name(Required)

Last Name(Required)

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Patient Name

First Last

Gender(Required)

Male

Female

Date of Birth(Required)

MM slash DD slash YYYY

Social Security Number

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Cell Phone(Required)

Work Phone

Home Phone

Email(Required)

Preferred Contact Method:(Required)

I authorize to receive electronic appointment reminders and messages.(Required)

Yes

Parent or Person responsible for account: (If patient is a minor, under 18 years of age.)(Required)

Yes

Name(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Phone(Required)

Address if different from above:(Required)

Yes

Address if different from above:(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Guardian/Guarantor Relationship:

Should the patient be a minor, a legal guardian must be present at every appointment in order to have services rendered.

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How were you referred to our office?

My Doctor

Friend/Family

Internet

Through Insurance

Drive By

I am a Previous Patient

Referring Doctor’s Name:

Emergency Contact: (Please include a phone number other than what is listed above)

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Emergency Contact:

Emergency Contact Name(Required)

Emergency Contact Phone(Required)

Emergency Contact Relationship:(Required)

I Authorize ONLY the following person/s to call and or request information about my PHI (Protected Health Information).

Authorize(Required)

Patient Only

Other: (name & relation to patient)

Other: (Authorization name & relation to patient)

Will you be using Insurance?(Required)

YES

No (I will be Self Pay / Pay out of pocket )

Payments made for medical services rendered are FINAL. No refunds will be issued.

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Not Using Insurance

Insurance Carrier:(Required)

ID#(Required)

Group#:(Required)

Policy Holder:(Required)

DOB:(Required)

MM slash DD slash YYYY

Relationship(Required)

ALL INSURANCE INFORMATION MUST BE ACCURATE AND UP TO DATE. We DO NOT back-file previous visits. We must be notified of any changes before scheduled appointments or you will be responsible for services rendered. It is your responsibility to obtain a referral if one is required by your insurance. Unpaid/Denied claims will be your responsibility.

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* For your convenience, our office accepts all Major Credit Cards / Debit Cards / Cash / Checks and Care Credit WE DO NOT ACCEPT WORKERS COMPENSATION INSURANCE

By signing below, I acknowledge the above information to be true to the best of my knowledge. I authorize Houston Foot Dr. to release any of my information required to process my claims. I have read and understand Houston Foot Dr.’s office policy (REV23). I am aware I may obtain a copy from the office at my request or online at www.houstonfootdr.com.

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Patient / Guardian Signature:(Required)

Date:(Required)

MM slash DD slash YYYY

Patient Clinical Information

Reason for visit:(Required)

When did it begin?

Have you seen another doctor for this?

Yes

If yes, who and when?

Was this problem caused by an accident or work related injury?

Accident

Work Injury

We do not accept Worker Comp but will gladly provide you with necessary paper work to submit your own claims.

Smoking Status:(Required)

Current

Former

Never

Shoe size:(Required)

Height:

Weight:

Any Surgical History:(Required)

Yes

Past surgical History: (Please include the year performed)

Any previous and current medical conditions.(Required)

Yes

Please check any previous and current medical conditions.

ADD/ADHD

Alzheimer’s Disease

Ankle Swelling

Arthritis

Asthma

Atrial Fibrillation

Blood Clots

Cancer

Cardio Vascular Disease

COPD

Depression/Anxiety

Diabetes

DVT

GERD

Gout

Headache/Migraine

Hepatitis

High Blood Pressure

High Cholesterol

HIV Positive

Kidney Disorders

Liver Disorder

Lung Disorder

Neuropathy

Parkinson

Poor Circulation

Seizures

Shortness of Breath

Stroke

Thyroid Disorder

Ulcers

Other conditions not listed above:(Required)

Allergic:(Required)

Yes

Please list any medications you are allergic to or have had adverse side effects to.(Required)

Any medications you are currently taking:(Required)

Yes

Please list any medications you are currently taking prescribed or over the counter and the reason*: (include dosage)(Required)

How would you like your prescriptions?(Required)

Print my prescription

Send to my Pharmacy

Pharmacy Name:(Required)

Phone:(Required)

Zip Code:(Required)

I authorize Houston Foot Dr to retrieve available prescription history when available.(Required)

Yes

* The above medications are true and complete. Omissions are unintentional and will be corrected at my responsibility. Interactions caused by my omission, is not the responsibility of HFD.

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*The above information is true and complete. Omissions are unintentional and will be corrected at my responsibility.

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