Patient Information
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1
2PATIENT INFORMATION
LAST
FIRST
M
PATIENT’S FULL NAME
DATE
ADDRESS
CITY
STATE
ZIP
PHONE
BIRTHDATE
AGE
MARITAL STATUS S M D W
SEX
PATIENT’S OCCUPATION
EMPLOYER
PHONE
PATIENT’S SOCIAL SECURITY #
NAME OF PERSON RESPONSIBLE FOR BILLS
RELATION TO PATIENT
SOCIAL SECURITY #
EMPLOYER
PHONE
ADDRESS IF DIFFERENT THAN PATIENT’S
REFERRED TO OUR OFFICE BY
PATIENT’S PHYSICIAN
CITY
MEDICARE#
EFFECTIVE DATE
OTHER INSURANCE CO.
GROUP/ POLICY#
CATERPILLAR ID#
In case of an emergency, whom could we notify OTHER THAN SOMEONE LIVING IN YOUR HOUSEHOLD?
NAME
ADDRESS
PHONE
RELATIONSHIP TO PATIENT
We acknowledge the presence of and need for insurance by our patients; however, the contract is between you and your insurance company. Each patient,
not the insurance company, is responsible for payment of all changes to his account at the time services are rendered. Yo assist you in obtaining reimburse-
ment for covered expenses we provide you with an insurance coded receipt that is properly marked for your insurance company. With this coded receipt
form it is not necessary for this office to fill out the insurance claim. Our customary fee will be charged for additional itemization of service.
PLEASE BE SPECIFIC IN ANSWERING THE FOLLOWING QUESTIONS
PATIENT’S MEDICAL STATUS
WHAT IS YOUR FOOT PROBLEM?
YES NO
YES NO
KIDNEY/LIVER PROB.
DIABETES
WHEN DID THIS PROBLEM START?
STOMACH/BOWEL PROB
HIGH BLOOD PRESS.
ASTHMA
HEART DISEASE
BLOOD DISEASE
ARTHRITIS
HAVE YOU HAD FOOT TREATMENT BEFORE?
CIRCULATION DISEASE
BURSITIS
BY WHOM?
EPILEPSY
LEG CRAMPS
CANCER
SMOKER
PLEASE LIST MEDICATIONS YOU ARE
ALLERGIES
CURRENTLY TAKING.
YES NO
YES NO
PENICILLIN
ADHESIVE TAPE
ASPIRIN
LOCAL ANESTHETIC
CODEINE
OTHER:
I hereby request and authorize the physicians of ACPM Podiatry Group, Ltd. to administer treatment and to perform such general procedures as they may
deem necessary in the diagnosis and/or treatment of my foot condition. This may include x-rays and/or photographs. I further certify that to the best of my
belief and knowledge, the information provided is true and accurate.
PATIENT’S SIGNATURE
DATE
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