PATIENT REGISTRATION FORM

Please provide a copy of your current insurance cards.

Co-Pay, Co-Insurance & Deductibles are expected at the time of service.
______________________________________________________________________________________________________________
Patient Information:
Last Name:________________________________
Date of Birth: _____________________________
First Name:________________________________
Patient Gender: Male ____ Female ____
Middle Name:______________________________
Marital Status: ___________________________
Address:___________________________________
Race: ____________________________________
City,State,Zip:_____________________________
Employer Name: __________________________
Home Phone#:(_____)_______________________
Address: __________________________________
Cell Phone#: (____)_________________________
City, State, Zip: ___________________________
Social Security #:__________________________
Phone: (_____)_____________________________
Email address: ____________________________
Occupation: ______________________________
How did you hear about our practice? __________________________________________________________
Family/PCP Physician:
Name:______________________________________
Pharmacy:
Name:____________________________________
Phone#:(_____)______________________________
Phone: #(____)___________________________
Fax#:(_____)________________________________
Fax#(___)_______________________________
Date last seen: ____________________________
Please check all methods we may utilize to speak with you or to leave you a detailed message:
Appointment Information
Medical Information
HOME Phone (including auto calls)


CELL Phone (including auto calls)


MOBILE Text (including auto calls)


WORK Phone


With another Person(s):


Email or Patient Portal:


Mail


Emergency Contact: *****Please list name of someone not living in your household*****
Name:______________________________________________________ Relationship to Patient: _______________
Phone#: Wk.(_____)_____________ Hm.(_____)________________
Complete Foot and Ankle Specialists, Inc. does not honor advanced directives.
We will call 911 to provide life support to any patient in distress.
After treatment, the patient will be turned over to their treating physician for continuing care.
INSURANCE INFORMATION:
*** Insurance Cards/Documentation must be given to front desk at time of service ***
Guarantor Information:
(Person responsible financially and/or patient is a minor)
Last Name:____________________________ First Name:___________________________ Middle Initial:______
Address:_____________________________________
City,State,Zip:______________________________________
Home Phone#:(_____)__________________________ Cell Phone#: #:(_____)_______________________________
Relationship to Patient: _______________________ Date of Birth: ______________________________________
Will this treatment be done as a result of:

Workers Compensation Injury:
Yes ____
No ____
Date of Injury: ___________________
WC Claim #: __________________ Managed Care Organization: ____________________________________
Claims Representative: ______________________________________ Phone #:(_____)___________________

Auto/Personal Accident:
Yes ____
No ____
Date of Injury: ______________________
Claim #: ________________ Auto/Home Owners Insurance: _______________________________________
Claims Representative: __________________________________ Phone #:(_____)_______________________
Health Insurance:
Primary Insurance:________________________________________ Referral Required Yes ___ No ___
Policy/ID #:_________________________________________________ Group #:_____________________________
Insured/Subscriber:________________________________________ Relationship to Patient:_______________
Social Security #: ___________________________________________ Date of Birth: ________________________
Insured Employer:___ ______________________________________________________________________________
Secondary Insurance:______________________________________ Referral Required Yes ___ No ___
Policy/ID #:_________________________________________________ Group #:_____________________________
Insured/Subscriber:________________________________________ Relationship to Patient:_______________
Social Security #: ___________________________________________ Date of Birth: ________________________
Insured Employer:___ ______________________________________________________________________________
INSURANCE AUTHORIZATION/ASSIGNMENT (PLEASE READ & SIGN)
I hereby authorize the physician to furnish information to my insurance carrier concerning my
condition and treatment. I hereby assign to the physician all payments for medical service rendered
to my dependent or myself. I understand that I am responsible for any amount not covered by my
insurance carrier. I agree to be held responsible for collection processing fees that may be added to
my account if collection action occurs.
Signature ____________________________________________ Date _____________________
(If the patient is a minor, the legal guardian must sign)
Patient Name:__________________________________________ Date of Birth:_____________________________
PATIENT MEDICAL INFORMATION
What condition(s) are you being seen for today?
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Please CIRCLE any of the following CONDITIONS that you currently have or have had:
Anemia
Bronchitis
Cancer
Colitis
Anxiety
Depression
Dermatitis
Peptic Ulcer
Asthma
Bleeding Disorder
Heart Disease
Kidney Disease
Kidney Stones
Lung Disease
High Cholesterol
Hepatitis
High Blood Pressure
Rheumatoid Arthritis
Osteoarthritis
Gout
PVD
Pneumonia
Thyroid Disease
Tuberculosis
Diabetes-Type 1
Diabetes-Type 2
Gallbladder problems
HIV+
OTHER: ___________________________________________________________________________________________
Please CIRCLE any of the following SYMPTOMS that you currently have:
Fever
Swollen ankles
Swollen feet
Swollen legs
Shortness of breath
Chest pain/tightness
Numbness
Tingling
Ulcers
Dry Skin
Calf pain
OTHER: ___________________________________________________________________________________________
Please CIRCLE any of the following SURGERIES that you have had:
Appendix
Gall Bladder
Joint Replacement
Tonsils
Catheterization
Hysterectomy
Orthopedic
Foot/Ankle Surgery
Cesarean
Heart/Leg Bypass Surgery (circle one)
Heart/Leg Stents (circle one)
Cataract
Pacemaker/Defibrillator (circle one)  Tonsils
OTHER: ___________________________________________________________________________________________
Please CIRCLE if you have been HOSPITALIZED for any of the following:
NONE
Trauma
Wound
Dehydration
Diabetes
Blood Clot
Diverticulitis
Pneumonia
Infection (Type :_____________________________________ OTHER: _____________________________________
Patient Name:__________________________________________ Date of Birth:_____________________________
Height: _________
Weight: ________
Shoe Size: ________
Mens: _____ Womens: _____
Smoker? Yes ____ No ____ If yes, how long? _________ How many packs a day? ________ Quit_______
Alcohol use? Yes ____ No ____ If yes, how many drinks per week? _________________________________
Drug use? Yes ____ No ____ If yes, type? ____ Marijuana ____ Illegal Prescription ____ IV ____Other
Smoke Less Tobacco? Yes ____ No ____ If yes, how long? _________ How often? ________ Quit_______
List Prescription Medications Currently Taking: (Please ATTACH List)
Name of Medication
Strength
Dosage
Frequency
1. ________________________________________________________________________________________________
2. ________________________________________________________________________________________________
3. ________________________________________________________________________________________________
4. ________________________________________________________________________________________________
5. ________________________________________________________________________________________________
6. ________________________________________________________________________________________________
7. ________________________________________________________________________________________________
8. ________________________________________________________________________________________________
9. ________________________________________________________________________________________________
10. _______________________________________________________________________________________________
11. _______________________________________________________________________________________________
12. _______________________________________________________________________________________________
Please CIRCLE any of the following to which you’ve had ALLERGIC REACTIONS to:
Adhesive Tape
Aspirin
Codeine
Latex
Penicillin
Iodine
Sulfa
Local Anesthetics (Novocain) OTHER : ____________________________________________________________
FAMILY History: Has any member of your immediate family been treated for the following?
(Please check all that apply AND circle the appropriate family member.)
F = Father
 Arthritis
 Cancer
 Diabetes
M = Mother
F M B Si So D
F M B Si So D
F M B Si So D
B = Brother
Si =Sister
So = Son
 High Blood Pressure
 Heart Disease
 Stroke
D = Daughter
F M B Si So D
F M B Si So D
F M B Si So D