ATLZ05 Patient Demographics

Atlantic Prosthetics & Orthotics - Patient Demographics Form
Patient Name*

First NameMiddle NameLast Name
Patient Date of Birth*

MonthDayYear
Date
Sex

MaleFemale
Social Security Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Marital Status

SingleMarriedWidowedDivorced
Are you a Veteran?

YesNo
Would you like your bills by

MailEmail
Home Phone Number
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Driver License Number
Email Address
example@example.com
Parent or Responsible Party (if patient is a child)
Address (if different from above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact
Emergency Contact Phone Number
Please enter a valid phone number.
Are you currently living in a Skilled Nursing Facility?

YesNo
If yes, Anticipated discharge date

MonthDayYear
Date
Medical Information
Weight
Height
Accident date

MonthDayYear
Date
State Accident Occurred in
Amputation date

MonthDayYear
Date
Referring Physician
Referring Physician Phone Number
Primary Physician
Primary Physician Phone Number
Physician that monitors your Diabetes
Have you had an orthopedic device, shoes, brace, or prosthesis in the last 3 years?

YesNo
If yes, how long have you had the brace?
What is the primary reason/diagnosis for the device you have been prescribed

Please check any conditions that apply to you

Other Health Conditions
Are you currently employed?

YesNo
How many hours a day are you on your feet?
Do you have a history of ulcers?

YesNo
Where are your ulcers?
We will verify your insurance for the device prescribed by your physician and advise you of coverage and any financial responsibility you may have. We cannot guarantee the benefits we quote to you as the insurance companies do not guarantee the benefits they quote to us on your behalf. Please refer to your insurance benefits handbook or call your insurance company for more information.
Digital Signature Authorization:*

I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.
Signature*

Clear
Date

MonthDayYear
Date
Should be Empty: