Scottsdale Neuropathy Institute Patient Form

PATIENT INFORMATION

Please complete the New Patient Forms. You may click Submit to have the completed form emailed to us automatically, Print out the form to complete and bring with you or Save the form to your computer.

(PLEASE PRINT)
First Name
MI Last Name
Sex
SSN DOB Age Ht Wt
Email Address
Address
Apt#
City
State Zip
Home #
Work # Cell #
Primary Physician
Date last seen
Primary language
Race Hispanic/Latino Yes No
Referred by
Emergency contact
Phone
Marital Status:
Single married legally separated divorced widowed partner
Student Status:
full time part time not a student
Employment Status:
full time part time not employed
Employer
Job Title
Address
Phone
City
State Zip

INSURANCE

Primary Insurance
Policy Holder’s Name
Relationship to patient
DOB SSN
ID#
Group# Insurance phone number
Secondary Insurance
Policy Holder’s Name
Relationship to patient
DOB SSN
ID#
Group# Insurance phone number

CONTACT PREFERENCES

What phone number can our office staff use to contact you regarding your personal health information and appointments?
Home Work Cell
May we leave a message at this number? Yes No
Who may we discuss personal health information with?
Who may we discuss appointment information with?

I hereby give Valley Foot Surgeons permission to treat me or my dependents as necessary. I understand my insurance company may assist me in paying all medical costs, but I am ultimately responsible for all medical services rendered and, if necessary, I agree to pay all reasonable and customary collection fees and/or attorney’s fees that may be incurred due to any delinquent accounts I may have. I authorize the release of any medical information necessary to process my claim to my insurance company. I also authorize payment of medical benefits to my physician, directly, for services rendered. I understand that I am financially responsible for my bill.

**As a courtesy, we will bill your insurance company for you**
Signature: Date:
 

MEDICAL HISTORY

Drug allergies
Medications
Are you diabetic Yes No   If yes, what type? Controlled Uncontrolled
Are you insulin dependent? Yes No

SOCIAL HISTORY

Do you smoke tobacco? Yes No Did you smoke? Yes No How much? How many years?
Do you drink alcohol? Yes No Did you drink? Yes No How much? How many years?
Do you use illegal drugs? Yes No If yes, how often?
What is your chief complaint today?
Do you have foot/ankle pain? Yes No Where is your pain?
How long have you had pain? When do you get the pain?
Any history of injury to this area? Yes No If yes, explain:
Any previous treatment? Yes No Treated by:
What treatment have you tried?

ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES

 I   acknowledge that a copy of VALLEY FOOT
(Name of Patient)
SURGEONS ‘Notice of Privacy Practices’ is displayed in the office lobby. I am also aware that I may request a copy of the ‘Notice of Privacy Practices’ from any member of the office staff. This notice describes how RICHARD P. JACOBY, D.P.M., P.C. (dba. VALLEY FOOT SURGEONS) may use and disclose my protected health information, certain restrictions on the use and disclosure of my healthcare information, and rights I may have regarding my protected health information.
(Signature of Patient, or Personal Representative - Just enter your name here, It will act as Signature) (Date)
(Relationship to Patient)

Name: Date:

PAST MEDICAL HISTORY: (check all that apply)

AIDS/HIV Diabetes Pacemaker
Arthritis Gout Parkinson’s
Blood Clot Hepatitis Polio
Bleeding Problems High Blood Pressure Rheumatic Arthritis
Circulation Problems High Cholesterol Stomach Problems
Cancer High Triglycerides Stroke
COPD Neuropathy
Other:

PAST SURGICAL HISTORY: (check all that apply)

Angioplasty Hammertoe surgery
Ankle surgery Hernia repair
Appendectomy Hysterectomy
Back Surgery Mastectomy
Bunionectomy Neuroma surgery
Bypass Vascular Surgery
Carpal Tunnel surgery Stent
C-section Nail removal
Eye Surgery Plantar wart removal
Foot surgery Thyroidectomy
Gallbladder Tonsillectomy
Other:

FAMILY HISTORY: (check all that apply)

Cancer
Cardiovascular Disease Diabetes
High Cholesterol Hypertension
Rheumatoid arthritis Stroke
Other: