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1-810-629-3338

Info@FentonFootCare.com

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- Diabetic Care Service
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- Dr James Hirt, DPM
- Dr Erin Holdren-Otis, DPM
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Home
About Us
Services
- Foot & Ankle Care Treatments
- Diabetic Care Service
Products
Doctors & Staff
- Dr James Hirt, DPM
- Dr Erin Holdren-Otis, DPM
Patients
Resources
Contact Us

Minors Patient

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Minors Patient

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Fenton Foot Care- 14229 Torrey Rd. Suite 1 Fenton, MI 48430

To Submit Prior to Appointment, Send Via fax, 810-629-9243 or email info@fentonfootcare.com
Patient Last Name*
Patient Legal First Name*
Middle Initial*
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Patient Date of Birth*
MM slash DD slash YYYY
Gender*
- Male
- Female
Section Break
Parent / Guardian Last Name*
Parent / Guardian Legal First Name*
Relationship to Patient*
Parent Social Security #*

Last 4 Digits Only
Parent DOB*
MM slash DD slash YYYY
Section Break
Address (No PO BOXs) :Street*
City*
State*
Zip*
Section Break
Home Phone*
Cell Phone*
Email*
Section Break
Parent Occupation*
Parent Employer*
Employment Status*
- Full Time
- Part Time
- Retired
- Unemployed
- Student
Section Break
Emergency Contact Name*
Relationship*
- Spouse
- Parent
Best Phone Number*
Section Break
Family Doctor*
Town*
Office Phone*
How did you hear about our office?*
What brings you in today?*
Duration*
Section Break
Insurance Carrier
Primary Ins. Carrier*
Name of Policy Holder*
Policy Number*
Policy Holder DOB*
MM slash DD slash YYYY
Section Break
Secondary Ins. Carrier
Name of Policy Holder
Policy Number
Policy Holder DOB
MM slash DD slash YYYY
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Name 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 History
Patient Shoe Size*

Please enter patient shoe size
Weight*
Height
Ft
Inch
Inch
Are you Diabetic
- Yes
- No
Physician that follows your diabetic care*
Date last seen by them*
MM slash DD slash YYYY
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Current Conditions - Mark NONE if the condition below does NOT apply to you
Symptoms :*
- 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 Break
Allergies
Allergies
- None
Mark NONE if the allergies below do not apply to you
Allergies Details
Section Break
Current Medications
Medication List can be copied & attached separately if available - You do NOT have to Rewrite medications
Do you take any medications?*
- None
- Will Bring a List
If you take medications, please fill out the section below.

Medication List

Medicine	Dosage	How Often

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Pharmacy you prefer to use
Pharmacy*
Location*
Zip*
Section Break
Past Medical History
Past Medical History
Social History
Smoking History
- Non Smoker
- Current Smoker
- Former Smoker
Packs per day
Years of Cessation
Section Break
Family History
Diabetes
- 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 Agree
Responsible 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 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 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?

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OFFICE INFORMATION

Mon: 8:00 am – 6:00 pm
Tues: 8:30 am – 4:30 pm
Wed: 8:30 am – 3:00 pm
Thur: 8:30 am – 4:30 pm
Fri: 8:30 pm – 12:30 pm
810.629.3338
810.629.9243
info@FentonFootCare.com

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