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.
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.
ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES
PAST MEDICAL HISTORY: (check all that apply)
PAST SURGICAL HISTORY: (check all that apply)
FAMILY HISTORY: (check all that apply)