Patient Registration Form

We are very pleased to have you with us. Please fill in all the appropriate blanks below. This information is important for your health and our records. If you need help, do not hesitate to ask. 

Patient Information



 





 





 




 



 


Yes No

 
Primary Insurance









Secondary Insurance









 
Podiatric History


Yes No


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Personal Family

 


Pills Insulin

 
About my Health

 

Adhesive/Tape
Anticoagulant Therapy
Aspirin
Codeine
Demerol
Iodine
Local Anesthetics
Novocaine
Penicillin
Seafoods
Sulfa
None

 




 
General Medical History

Place a mark on "Yes" or "No" to indicate if you have had any of the following:


Yes No


Yes No


Yes No


Yes No


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Yes No


Yes No


Yes No


Yes No


Yes No


Yes No


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Yes No


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Please complete all sections



 



Yes No

If yes, whom?


 


 


 
Assignment of Insurance Benefits

I understand my signature authorizes the release of all information necessary to secure the payment of benefits from my insurance or agency. I hereby authorize Medicare, Medicaid, and/or the to pay NE Ohio Foot, Ankle & Wound Center Inc. the medical and surgical benefits allowable and otherwise payable under my Insurance Policy. I understand I am financially responsible to NE Ohio Foot, Ankle & Wound Center Inc. for charges not covered by this assignment.



 
 

I hereby give my permission to NE Ohio Foot, Ankle & Wound Center Inc. to examine, photograph, administer treatment, and to perform such minor operative procedures as may be deemed necessary in the diagnosis and/or treatment of my foot problem.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.