Full Name                                                                    Preferred Name                                                                                                                                                                                                                                Street Address                                                City                               State                    Zip Home Phone (         )                          Work Phone (       )                         Cell (       )                           BirthDate                                  SS#_____\_____\_____  Marital Status                        Sex    F     M Employer Name & Address:                                                                                                                                                                                                                                                                                               Emergency Contact:                                                                        Relation:                                             Emergency Contact Phone # (      )                                                                                                              Reason for Today's Visit                                                                                                                             Primary Care Physician_______________________ Date of Last Visit_________________ * Required information for all Medicare patients. How did you hear of our office:__________________________________________                                             please provide name of person/ Dr. that is referring Insurance Information: Name of insurance carrier:                                                                                                                        Policy #__________________________  Group #__________________________ Please be prepared to present your insurance card, so that we may make a copy for our files. It is the policy of this practice to collect any unpaid deductibles,co-payment and fees for non-covered services at the time of service Name of Insured (if other than the patient)                                                                                             Date of Birth                                           SS#                                                  Relation:                             Employer/Address of Insured                                                                                                                                                                                                                                                                                        I hereby authorize the release of any medical information necessary for the processing insurance claims and payment of medical benefits to myself or the party who accepts assignments. I understand that a claim will be filed with all contracted carriers, however I am responsible for any amount not paid by my insurance company. It's our policy at Carmel Foot Specialists to identify & verify benefits for service. The benefits discussed represent information currently available to us at the time of service. Your insurance company WILL NOT GUARANTEE payments of benefits under ANY plan. Claims are subject to all plan terms and provisions. This means that the benefits payable are determined according to the insured's eligibility, the limitations and exclusions (including pre-existing limitations) and conditions of the plan. Benefit determination of the claim payment will be made at the point the claim is processed unless otherwise excluded from your plan. We will not file for those services excluded or non authorized as determined by your carrier. Therefore NON-COVERED or UNAUTHORIZED services are not subject to negotiated rates & you will be responsible for these charges. Date____________   Signature of Patient/Gaurdian_________________________

Patient Medical History

Name                          ___                                                          Date:_____ __________
Shoe size:                                    Weight:                                   Height:                              
Occupation:                                                                          Race:                                     

Do you have or have you ever been treated for:

Stroke	Heart Attack	Glaucoma	High Blood Pressure
Phlebitis	Vascular Disease	Lung Disease	A Heart Condition
Diabetes	Poor Circulation	Stomach Ulcer	Headaches
Hepatitis	Liver Disease	Thyroid Problem	Anemia
Gout	Arthritis	Tuberculosis	Osteoporosis
Alzheimer	Keloid/Thick Scar	Cancer	Hearing/Ear Disorder
Epilepsy	Nerve Disorder	HIV/AIDS	Psychiatric Disorder
Sciatica	Rheumatic Fever	Lyme Disease	Other

Do you have a family history of:

Diabetes	Cancer	High Blood Pressure
Arthritis	Foot Problems	Birth Defects
Stroke	Heart Attack	Other:

Please list all surgeries:                           ____                                                                     
                                      ________                                                                                                      
                                                                                                                      ___                      

Do you Smoke________

Drink alcoholic beverages ______

Use recreational drugs______________

Do you have: Heart valve replacement______	Joint Implants ______	Vascular graft_________

Do you have allergies to:

Penicillin	Demerol	Adhesive tape
Sulfa Drugs	Novocain / Lidocaine	Motrin / Aleve / Advil / Aspirin
Other antibiotics	Iodine/ Shrimp	Tylenol
Codeine	Other:

Current Medication Lists: __________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

ACKNOWLEDGMENT OF RECEIPT

OF

NOTICE OF PRIVACY PRACTICES

I acknowledge that I was offered or provided with a copy of the

Notice of Privacy Practices and that I have read

(or had the opportunity to read if I so chose) & understood the notice.

                        _____________________________________                                                                        Patient Name (print)

                        ______________________________________

                        Parent/Authorized Representative/ Parent (if applicable)

Authorization for release of information

I hereby authorize Carmel Foot Specialists to disclose my individual medical information to the person listed below. I understand that this authorization is voluntary and will not expire, however it may be revoked at any time by notifying Carmel Foot Specialists in writing.

Person(s) allowed to receive my medical information               Relationship to patient

Signature & Date ______________________________/_______________________