123 Fenton Foot Care- 14229 Torrey Rd. Suite 1 Fenton, MI 48430 To Submit Prior to Appointment, Send Via fax, 810-629-9243 or email [email protected] Patient Last Name* Patient Legal First Name* Middle Initial* Section BreakPatient Date of Birth* MM slash DD slash YYYY Gender* Male Female Section BreakParent / Guardian Last Name* Parent / Guardian Legal First Name* Relationship to Patient* Parent Social Security #* Last 4 Digits OnlyParent DOB* MM slash DD slash YYYY Section BreakAddress (No PO BOXs) :Street*City* State* Zip* Section BreakHome Phone*Cell Phone*Email* Opt in to receive text messages* Yes, I would like to receive texts from Fenton Foot Care. No, I do not wish to receive texts from Fenton Foot Care. Section BreakParent Occupation* Parent Employer* Employment Status* Full Time Part Time Retired Unemployed Student Section BreakEmergency Contact Name* Relationship* Spouse Parent Best Phone Number*Section BreakFamily Doctor* Town* Office Phone*How did you hear about our office?* What brings you in today?* Duration* Section BreakInsurance CarrierPrimary Ins. Carrier* Name of Policy Holder* Policy Number* Policy Holder DOB* MM slash DD slash YYYY Section BreakSecondary Ins. Carrier Name of Policy Holder Policy Number Policy Holder DOB MM slash DD slash YYYY Section BreakName of person(s) who can access your records/PHI or pick up records.First & last name and relationship: First & last name and relationship: First & last name and relationship: Terms and Conditions Accept term*I do hereby attest that this information is true, accurate, and complete to the best of my knowledge, I understand that any falsification, omission, or concealment of any material fact may subject me to all fees for services and/or other liability. i also understand that i am to notify fenton foot care immediately of any changes to the above information and annually upon the office's request, I also acknowledge that I have been provided the opportunity to take and review the office's HIPAA policy, Authorization from Patient or Legal Representative and Notification of Office Policies and Procedures (Version 01-01-2017). (Available in our waiting room and/or by request). I further acknowledge and accept all the terms and conditions in all forms listed including "notifications of office policies and procedures"."HIPAA policy Notice of Privacy Practices". and "Authorization from patient or legal representative". I authorize Fenton Foot Care to contact me via text and email(MSG & Date rates apply) I Agree Attest to submission* By typing in your full name in this field you are agreeing to the terms and conditions related to the online submission of your information.Terms of agreement date* MM slash DD slash YYYY Date of the agreement to term of online submission of patient information. Current Medical HistoryPatient Shoe Size* Please enter patient shoe sizeWeight*Height3'4’5’6’FtInch01234567891011InchAre you Diabetic Yes No Physician that follows your diabetic care* Date last seen by them* MM slash DD slash YYYY Section BreakCurrent Conditions - Mark NONE if the condition below does NOT apply to youSymptoms :* None Chills Fever Nausea Vomiting Neurological :* None Numbness/Nerve Pain Seizures Strokes Skin :* None Cellulitis/Infection Fungal Nails Ingrown Nails Sores Rash Warts Vascular :* None NoneLeg/Calf Cramping Cold Feet Leg/Calf Cramping at rest Skin red/ Pale/ Purple Section BreakAllergies Allergies None Mark NONE if the allergies below do not apply to youAllergies DetailsSection BreakCurrent MedicationsMedication List can be copied & attached separately if available - You do NOT have to Rewrite medicationsDo you take any medications?* None Will Bring a List If you take medications, please fill out the section below.Medication ListMedicineDosageHow Often Section BreakPharmacy you prefer to usePharmacy* Location* Zip* Section BreakPast Medical HistoryPast Medical HistorySocial HistorySmoking History Non Smoker Current Smoker Former Smoker Packs per day Years of Cessation Section BreakFamily HistoryDiabetes Father Mother Heart Attack Father Mother Cancer Father Mother Other Father Mother Other Details Other Details Section Break Responsible Party - For Minors (Under 18) or patients under medical Power of Attorney/Guardianship Responsible Party**The Primary individual who accompanies a child (18 or under) to Fentom Foot Care is responsible for all fees, regardless of guardianship or custody arrangements. All patients 18 or under must be accompanied by an adult, Responsible Party, at every appointment. If the patient arrives unaccompanied to any appointment the patient will not be seen and the appointment will be rescheduled to a time when the patient can be accompanied by a responsible adult. I AgreeResponsible Party*As the responsible party, If you are unable to bring the patient to their appointment you can approve up to 3 alternate adults that you consent to bring the patient to their appointment and make medical decisions for the patient in your absence. We will not be able to see the patient if they are not accompanied by a parent or an approved alternate adult listed below. Please note that all approved parties must be prepared to pay a copayment, co-insurance, and /or outstanding balance when applicable. I AgreeAttest to submission* By typing in your full name in this field you are agreeing to the terms and conditions related to the online submission of your information.Terms of agreement date* MM slash DD slash YYYY Date of the agreement to terms of online submission of patient information.1st Alternate: First & last name and relationship to patient? 2nd Alternate: First & last name and relationship to patient? 3rd Alternate: First & last name and relationship to patient?
