Chart #
Patient Name:_________________________________ DOB:______________
Describe your foot problem?
_____________________________________________________________________________________
_____________________________________________________________________________________
What medications do you take regularly?
_____________________________________________________________________________________
_____________________________________________________________________________________
List any allergies:
_____________________________________________________________________________________
Any previous surgeries?
_____________________________________________________________________________________
PROBLEMS/ROS
[ ] Heart
[ ] Asthma or Breathing Difficulty
[ ] Scarring Tendency
[ ] Diabetes
[ ] Stomach Ulcers
[ ] Gout
[ ] Circulation
[ ] Hormones
[ ] Tuberculosis
[ ] Arthritis
[ ] Anemia
[ ] Rheumatic Fever
[ ] Kidneys
[ ] Bladder
[ ] Liver [ ] Spleen
[ ] Lungs
[ ] High Blood Pressure
[ ] Eye, Ear, Nose or Throat
[ ] Cancer__________
[ ] Hepatitis A-B-C
[ ] Unexplained Fever
[ ] HIV Positive/AIDS
[ ] Convulsions
[ ] Weight loss
[ ] Strokes
[ ] Numbness in feet___ or legs___
[ ] Skin
[ ] Bleeding Tendency
[ ] Cramps in feet___ or legs___
[ ] Frequent infections
[ ] Healing
[ ] Emotional or psychiatric disorder
[ ] Neurological Disorder
Any artificial joints?
Any metal (pins, plates, etc.) in your body?
[ ] HIP [ ] KNEE
[ ] YES
[ ] NO
[ ] Other_____________
Where?_________________________
Do you have any artificial Heart Valve Implants? YES NO
FAMILY HISTORY
Mother
LIVING
DECEASED
Cause of death__________________________
Father
LIVING
DECEASED
Cause of death__________________________
Brother
LIVING
DECEASED
Cause of death__________________________
Sister
LIVING
DECEASED
Cause of death__________________________
Check [ ] and list family members (blood relative) history of:
[ ] Heart Disease_________________________________________________________
[ ] Arthritis______________________________________________________________
[ ] Bleeding Disorder______________________________________________________
[ ] Neurological Disorder___________________________________________________
[ ] Stroke________________________________________________________________
[ ] Circulation problems in legs or feet_________________________________________
Do you Smoke? YES NO
Previously smoked? YES NO
Do you drink? YES NO
Are you pregnant? YES NO
ASSIGNMENT OF BENEFITS
I Hereby authorize payment to Brian E. Sicher, DPM or Mark A Gerig, DPM. I hereby agree that
in the event that payment by a third party for any individual visit exceeds that necessary to
cover charges incurred during that visit, any coverage may be applied to outstanding charges
owed the clinic for other services rendered to myself, my spouse, or legal dependents of myself
or spouse at the time. I acknowledge that I am financially responsible for non-covered services
and any unpaid insurance balance over 45 days past due.
I certify that the information given is correct. I authorize any holder of medical or other information
about me to release to the Social Security Administration or its intermediaries or carriers any
information needed for this or related medical claim.
Brian E. Sicher, DPM or Mark A Gerig, DPM may disclose all or part of this patient’s record to any
insurance company, physician, clinic, hospital, or laboratory. I understand that the information released
may include information pertaining to mental or psychiatric related conditions. A copy shall be valid as
the original.
I also acknowledge that any incision made into the skin is categorized by the American Medical
Association as a surgical procedure. This includes wart removal, ingrown nails, steroid injections and
nay incision and drainage procedure. Office visit co-pays don’t apply to these procedures; these
procedures are usually subject to a calendar year deductible. Please ask the office staff if you have any
questions regarding this matter.
Please be aware that we will file your insurance, but you will be responsible at
the time of service for any co-pay, co-insurance, or unmet deductible amount.
We would also like you to know front that most services performed by Dr. Brian
E. Sicher, DPM or Mark A Gerig, DPM are surgical procedures and will be
applied to your deductible, set co-pay amounts are for the office visit codes only.
Therefore, additional payment from the patient is usually required. Please see
the receptionist with any questions or an explanation of this statement.
PATIENT NAME ______________________________________________
SIGNATURE_________________________________________________
DATE_______________________________
RECEIPT ACKNOWLEDGMENT
OF
NOTICE OF PRIVACY PRACTICES
I acknowledge that I understand the notice and have the opportunity to read the Notice of Privacy
Practices if I so choose (posted in our office) or I can be given a copy if requested.
_____________________________
______________
Patient Name (please print)
Date
_____________________________
____________________
Parent or Authorized Representative
E-mail Address / IQ HEALTH
_____________________________
Signature
PATIENT INFORMATION
Patient Name ___________________________________ Sex: F___ M ___ Date _____________
Address ______________________________City _________________ State ___ Zip _________
Home Phone (
)_____________ Cell (
)______________ Work (
) ______________
Date of Birth ________________________ Age ________ SS# ___________________________
Patient’s Employer _______________________________ Occupation ______________________
Name of Insurance _____________________ Policyholder’s Name ________________________
Policyholder’s Address ________________________________ Phone ( ) _________________
Policyholder’s Date of Birth ________________ Policyholder’s SS# ________________________
Spouse’s Name ________________________ If Minor, Parents’ Name _____________________
Spouse’s Employer _____________________
Nearest Relative _____________________ Address ______________________Phone_________
Referred By: __ Physician (Name) __________________
__ Phone Book
__ Patient (Name) ____________________
__ Other _____________________