TFCZ01 New Patient Intake Form

New Patient Intake Forms
Patient Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Internet/GoogleFriend/FamilyInsurance CompanyFacebookReferring Doctor
Other way you heard about Dr. Davis/The Foot Clinic not listed above?
SingleMarriedDivorcedWidowedStudent
MaleFemaleTransgender FemaleTransgender MaleNon-Binary
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Home Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Please attach a photo of the patient’s government issued ID. If the patient is a minor, please attach a photo of the parent/guardian’s ID. Acceptable IDs include driver’s license, passport, military ID, etc. Please ensure that these IDs are valid and not expired. You can you your cell phone to take the picture.

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YesNo
Please attach a photo of the FRONT side of your PRIMARY insurance card. You can use your cell phone to take the picture.

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Please attach a photo of the BACK side of your PRIMARY insurance card. You can use your cell phone to take the picture.

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YesNo
Please attach a photo of the FRONT side of your SECONDARY insurance card. You can use your cell phone to take the picture.

Cancelof
Please attach a photo of the BACK side of your SECONDARY insurance card. You can use your cell phone to take the picture.

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Local Pharmacy Name & cross streets*
Local Pharmacy Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Primary Care Physician *
If you take prescription medications and are unable to list them here (including dosages), please contact our office before your appointment. We need this information ahead of time to prepare for your visit.
Current Medications - include dosage and how often you take the medication*
Allergies - Include the reaction you experienced. *
Tobacco Use *
Alcohol Use *
Occupation *
Emergency Contact Name

First NameLast Name
YesNo
Relationship
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
What is your main foot complaint?
When did this problem first start?
SharpDullBurningNumbnessThrobbingRadiatingGeneralLocal
What causes pain?
What makes pain worse?
What have you done to help this problem?
If another doctor treated you for this problem, what was done?
HIPAA ACNKNOWLEDGEMENT AND CONSENT
I give permission for reasonable and necessary medical examinations, testing and treatment to be performed at The Foot Clinic, by the physician. By signing below, I am indicating that: (1) I intend that this consent is continuing in nature even after a specific diagnosis has been made and treatment recommended. (2) I consent to treatment at The Foot Clinic or any other satellite location under the care of Dr. Davis. (Patient Initials)*
I have the right to discuss the treatment plan with the physician about the purpose, potential risks and benefits of any test ordered for myself/my child. If I have any concerns regarding any test or treatment recommend by the health care provider, I am encouraged to ask questions. I give consent for The Foot Clinic to leave test results, orders, referral information and appointment reminders on my voicemail if unable to reach me personally. (Patient Initials) *
Disclosure to family and/or friends:

I give permission for my Protected Health Information (PHI) to be disclosed for purposes of communicating results, findings and care decisions to the family member and others listed below.:

Rows	Name	Relationship	Phone Number
1.
2.
3.
4.

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*

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Name

First NameLast Name
Date

MonthDayYear
Date
The consent will remain fully effective until it is revoked in writing.
You have the right at any time to discontinue services.
Financial Responsibility Disclaimers
1. The Foot Clinic will collect your deductible, co-pay, uncovered services, or coinsurance you are responsible for at the time of your visit. It is the patient’s responsibility to know the terms of their insurance plan. Please be prepared to pay copays and balances at the time of service. If you have not met your deductible, we will collect payment for the estimated amount allowed by your insurance plan or New Patient visits are $100; Follow up visits are $50.
2. If your insurance denies payment on your account, you will be asked to pay by check, cash, or charge.
3. You may receive statements or notifications via text message and/or e-mail.
4. TERTIARY: The Foot Clinic will submit claims to primary and secondary insurances only. It is your responsibility to provide your third insurance with a billing statement of any remaining unpaid charges. Please be aware that any amount remaining AFTER insurance processes a claim is your financial responsibility.
5. NO SHOW POLICY: See below.
6. COLLECTIONS: Should your account become delinquent and over 90 days old, you will need to contact our billing department to establish a payment arrangement before making another appointment.
7. RETURNED CHECKS: There is a $40 charge for returned checks or declined credit card charges from mailed in payments.
8. SELF-PAY PATIENTS: This category includes patients with no insurance and the patients who have an insurance plan with which we do not participate or an insurance plan that does not provide podiatry benefits. Payment for medical services is required prior to services being rendered. We accept Visa, MasterCard, Discover and American Express, checks, cash, and money orders.
9. PRIOR AUTHORIZATION: The Foot Clinic does not provide Prior Authorization services. We apologize for the inconvenience.
10. An administrative collection fee of 28% will be added to all accounts over 90 days past due.
V. NO SHOW POLICY: Appointments missed without notice or cancelled less than 24 hours’ notice will be subject to the $50 No Show Fee. LATE ARRIVAL TO APPOINTMENTS WILL BE SUBJECT TO A $50 FEE. TWO NO-SHOWS IS AN AUTOMATIC DISMISSAL FROM THE PRACTICE. (Initial Below)*
By signing below, I acknowledge I have read these disclaimers.
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
Name

First NameLast Name
Date

MonthDayYear
Date
Should be Empty: