PATIENT INFORMATION
First Last
Name: 
Sex: 
Male   Female  
Birth Date: 
/ /   Age: 
Marital Status:   Married   Single   Widowed   Divorced  
Address: 
City: 
State: 
  Zip: 
Email: 
Day Phone: 
( )   – 
Social Security Number: 
 –   – 
Drivers License Number: 
Emergency Contact Numbers: 
PATIENT EMPLOYMENT INFORMATION
Employer: 
Occupation: 
Business  Address: 
City: 
State: 
  Zip: 
Work Phone: 
( )   –   Ext.
PATIENT SCHOOL INFORMATION
Full Time   Part Time   Not in School  
School Attending: 
RESPONSIBLE (INSURED) PARTY
Name: 
Relation to Patient: 
Address: 
City: 
State: 
  Zip: 
Employer: 
Employer Phone Number: 
( )   – 
Social Security Number: 
 –   – 
Primary Care Physician: 
Date Last Seen: 
How were you refered to our Office?
Check one:   Newspaper   Yellow Pages   Website   Family  
Friend   Insurance Plan   Physician  
Other: 
IT IS YOUR RESPONSIBILITY TO MAINTAIN A CURRENT REFERRRAL IN ORDER TO SEE THE PHYSICIAN LISTED ABOVE.
Which office location do you want to schedule?

*
Is there a particular physician you would like to see?

*
MEDICAL INFORMATION
My foot problem is (please describe):

Length of pain/problem: 
Shoe Size:  Height:  Weight: 
Work related?   Yes   No  
Date of injury: 
PLEASE CHECK ANY OF THE FOLLOWING YOU NOW HAVE OR HAVE HAD PREVIOUSLY:
 
Gout         Yes   No  
Anemia         Yes   No  
Cancer         Yes   No  
Asthma         Yes   No  
Hepatitis         Yes   No  
Epilepsy         Yes   No  
Arthritis         Yes   No  
Ulcers         Yes   No  
Fainting         Yes   No  
Hay Fever         Yes   No  
Circulation Problems         Yes   No  
Kidney Problems         Yes   No  
Stomach Problems         Yes   No  
Heart Trouble         Yes   No  
Thyroid Problems         Yes   No  
High Blood Pressure         Yes   No  
Shortness of Breath         Yes   No  
Bleeding Disorders         Yes   No  
Muscular Disorders         Yes   No  
Healing Difficulties         Yes   No  
OTHER:       
Are you Diabetic?   Yes   No  
Insulin Dependent?   Yes   No  
Diet Controlled?   Yes   No  
Doctors Seen for Diabetes: 
 
Have you ever experienced any ALLERGIES or ADVERSE EFFECTS to any of the following?
 
Penicillin         Yes   No  
Adhesives/Tape         Yes   No  
Novacaine         Yes   No  
Iodine (IVP dye)         Yes   No  
Codeine         Yes   No  
Aspirin         Yes   No  
Local Anesthetics       Yes   No  
Sulfa Drugs         Yes   No  
OTHER:        
Do you have metal implants?   Yes   No  
SOCIAL HISTORY
 
Alcohol         Yes   No  
Recreational Drugs         Yes   No  
Smoker         Yes   No  
Pregnant         Yes   No  
HIV Positive         Yes   No  
OTHER SOCIAL HABITS:        
FAMILY HISTORY
 
High Blood Pressure         Yes   No  
Blood Clots         Yes   No  
Cancer         Yes   No  
Heart Disease         Yes   No  
Tuberculosis         Yes   No  
Sickle Cell         Yes   No  
Diabetes         Yes   No  
Liver Disease         Yes   No  
Emphysema         Yes   No  
Kidney Disease         Yes   No  
Thyroid Problems         Yes   No  
OTHER GENTIC DISORDERS:        
MEDICATIONS
 
PLEASE LIST ANY MEDICATIONS ( prescription or over the counter) CURRENTLY TAKING (with Dosage)

 
Please list all surgeries and approximate dates.

INSURANCE INFORMATION
 
Primary Coverage
Insured's Name 
Employer 
Social Security Number: 
 –   – 
Insurance Company Name 
Group ID 
Address 
City: 
State:  Zip: 
Insurance Phone
  
Insured's Date of Birth
( )   –       / /
Effective Date 
 
Secondary Coverage
Insured's Name 
Employer 
Social Security Number: 
 –   – 
Insurance Company Name 
Group ID 
Address 
City: 
State:  Zip: 
Insurance Phone
  
Insured's Date of Birth
( )   –       / /
Effective Date 
 

All Doctors at the Foot & Ankle Center of North Houston, P.C. are Participating Providers of Medicare. This means that we accept the fee Medicare approves for our services. The patient or secondary insurance is responsible for the difference in what Medicare approves and what they pay ($100.00 deductible/year and 20% copay at each visit). We file all Medicare claims for our patients.

We also accept Medicaid. This also means that we accept what Medicaid allows for our services. If Medicaid does not approve a procedure, the patient is responsible for those charges.

We are participating providers on a number of insurance programs such as HMO's, PPO's, and POS's. This means we accept what the insurance program's determination for our services. If your insurance denies a service, the patient and/or responsible party is responsible for those charges. We do call and verify all procedures in most cases, before any treatment is rendered, so the patient is informed in advance. At that time, you will be given the option to proceed with the prescribed treatment, make financial arrangements or decline the treatment.

If your insurance company requires a specific form, please provide the form with your portion completed and sign at the time of service. If any of the above applies to you, please provide us with your insurance card(s) so that we can make copies for our file.

*I agree to be responsible for any charges that my insurance does not cover.

*PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE. I authorize the release of any medical or information necessary to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignments below.

*INSURED'S OR AUTHORIZED PERSON'S SIGNATURE. I authorize payment of medical benefits to the physician's listed here in.

**PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE. I authorize photographs to be taken of my foot or ankle disorder. Any photographs taken are property of The Foot and Ankle Center of North Houston, P.C. and may be used for teaching studies, insurance appeals, etc. Identity markings will be removed prior to reproduction.
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