New Patient Registration Form

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Basic Information

Patient's Name *

First

Last

Sex *

Male
Female

Date of Birth *

Age

Social Security Number

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Emergancy Contact

Emergancy Contact *

First

Last

Relations to Emergancy Contact?

Parent
Spouse
Child
Sibling
Friend

Emergancy Contact Phone

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Patient Contact Information

Email *

Cell Phone *

Home Phone

Other Phone

Mailing Address *

Address Line 1

City

State

Zip Code

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Employment Information

If patient is not employeed you may skip this section.

Patient's Employer

Work Phone

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Basic Medical Information

Primary Care Physician

Primary Care Phone #

Were you referred by your primary care physician?

Perfered Pharmacy

Call's Pharmacy
Wal Mart - Taylor
Wal Mart - Show Low
Walgreens - Show Low
CVS - Show Low
Other

Other Pharmacy

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Responsible Party Information

Leave blank if self

Responsible Party's Name

First

Last

Responsible Party's Sex

Male
Female

Responsible Party's Date of Birth

Responsible Party's Age

Responsible Party's Address (If different then patient)

Address Line 1

City

State

Zip Code

Responsible Party's Home Phone

Responsible Party's Cell Phone

Responsible Party's Employer

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Insurance Information

Will you be using Insurance or Cash Pay? *

Insurance
Cash Pay

Will you be using a secondary insurance? *

Is this a work related injury? *

Primary Insurance Name

Primary Insurance Policy Holder

Primary Insurance DOB

Primary Insurance ID Number

Primary Insurance Group Number

Primary Insurance Employer

Secondary Insurance Name

Secondary Insurance Policy Holder

Secondary Insurance DOB

Secondary Insurance ID Number

Secondary Insurance Group Number

Secondary Insurance Employer

Date of Injury

Carrier

Claim #

Adjustor

Adjustor Phone #

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Chief Complaint

What is the nature of your pain? *

Sharp
Dull
Achy
Throbbing
Tingling
Shooting

Where is your pain located? *

How long ago did your pain start? *

Did your pain come on suddenly or gradually? *

Suddenly
Gradually

Is your pain getting: *

Better
Worse
Staying the Same

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Review of Symptoms

Select all that apply

Constitutional

Chills
Fever
Fatigue
Weight Gain
Weight Loss

Cardiovascular

Chest Pain
Hair Loss on Legs
Replacement Heart Valve
Vascular Grafts
Cramps in Legs/Feet
Leg/Foot Ulcers
Extremities Cool
High Blood Pressure
Palpitations
Swelling of Legs
Varicose Veins
Extremities Discolored

Skin

Athlete's Foot
Fungal Nails
Itching
Mole Changes
Dryness
Hives
Keloid Scar
Rashes
Eczema
Ingrown Nails
Lumps
Warts

Neurological

Burning
Neuromas
Strokes
Unsteady Gait
Charcot Neuroarthropathy
Numbness
Tingling

Musculoskeletal

Ankle Sprain
Back Problems
Bunions
Corns
Gout
High Arch Feet
Joint Pain
Restricted Motion
Arch Pain
Broken Ankle
Calluses
Flat Feet
Hamer/Mallet Toes
In-toeing
Joint Stiffness
Muscle Cramps
Orthotic Use
Shoe Insert Use
Broken Foot Bone
Childhood Foot Problems
Gait (Walking) Problems
Heel Pain
Joint Implants
Knee Pain
Muscle Stiffness
Paralysis
Toe Walking

Allergies

Medications *

Family History

Surgical History

Medical History

Anemia
Anxiety
Arthritis
Asthma
DHP
Back Problems
Breast Cancer
DAD
CHF
COPD
Cancer Cholesterol High
Dementia
Depression
Dermatitis
Diabetes
Epilepsy
GERD
Glaucoma
Gout
HIV
Headache
Hepatitis
Hypertension
MI
Migraine
Pneumonia
Renal Stone
Stroke
TB
Thyroid Ds
Ulcer (GI)

Chack all that apply

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Social History

Tobacco History

Current Tobacco User
Former Tobacco User
Never Used Tobacco

Current Daily Usage

Number of Packs Per Day

Date Last Used Tabacco

Number of Years Smoking

Number of Packs Per Day

Achohol History

Beer
Wine
Hard Liquor
No Alcohol History

Beer

Social
Occasional
Light
Heavy

Wine

Social
Occasional
Light
Heavy

Hard Liquor

Social
Occasional
Light
Heavy

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Other Personal Information

Shoe Size

Shoe Type

Mens
Womens

Shoe Width

Regular
Wide

Height

Feet and Inches

Weight

Pounds

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Acknowledgement of Receipt of Notice of Privacy Practices

I acknowledge that I was provided a copy of the Notice of Privacy Practices and that I have read (or had the opportunity to read if I so chose) and understood the Notice.

Notice of Privacy Practices to Our Patients:

This notice describes how health information about you (as a patient of AACI Foot, Leg and Ankle care) may be used and disclosed, and how you can get access to your health information. This is required by the Privacy Regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPPA).

Our Commitment to your Privacy:

Our practice is dedicated to maintaining the privacy of your health information. We are required by law to maintain the confidentiality of your health information. We realize that these laws are complicated, but we must provide you with the following information:

Use and disclosure of your health information in certain special circumstances:

The following circumstances may require us to use or disclose your health information:

1. To public health authorities and health oversight agencies that are authorized by law to collect information.

2. Lawsuits and similar proceedings in response to a court or administrative order.

3. If required to do so by a law enforcement official.

4. When necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. We will only make disclosures to a person or organization able to prevent the threat.

5. If you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate authorities.

6. To federal officials for intelligence and national security activities authorized by law.

7. To correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official.

8. For Workers Compensation and similar programs.

Your rights regarding your health information:

1. Communications: You can request that our practice communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home rather than at work. We will accommodate reasonable requests.

2. You can request a restriction in our use or disclosure of your health information for treatment, payment, or health care operations. Additionally, you have the right to request that we restrict our disclosure of your health information to only certain individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you.

3. You have the right to inspect and obtain a copy of the health information that may be used to make decisions about you, including patient medical records and billing records, but not including psychotherapy notes. You must submit your request in writing to (Squire Foot and Ankle PLLC Chad A. Squire, Privacy officer, 932 S. Main St. Unit B203, Snowflake, AZ, 83937).

4. You may ask us to amend your health information if you believe it is incorrect or incomplete, as long as the information is kept by or for our practice. To request an amendment, your request must be made in writing and submitted to (Squire Foot and Ankle PLLC Chad A. Squire, Privacy officer, 932 S. Main St. Unit B203, Snowflake, AZ, 83937). You must provide us with a reason that supports your request for amendment.

5. Right to a copy of this notice. You are entitled to receive a copy of this notice of Privacy Practices. You may ask us to give you a copy of this Notice at any time. To obtain a copy of this Notice, contact our front desk receptionist.

6. Right to file a complaint. If you believe your privacy rights have been violated, you may file a complaint either directly with the practice, or to the Secretary of the Department of Health and Human Services. To file a complaint with our practice, contact (Squire Foot and Ankle PLLC Chad A. Squire, Privacy officer, 932 S. Main St. Unit B203, Snowflake, AZ, 83937). All complaints must be submitted in writing. You will not be penalized for filing a complaint.

7. Right to provide an authorization for other uses and disclosures. Our practice will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. If a disclosure of your protected health information was made for a reason other than treatment, payment or health care operations, you have a right to receive an accounting of the disclosures.

If you have any questions regarding this notice or our health information privacy policies, please contact Squire Foot and Ankle PLLC at (928) 457-0961 for further questions.

Privacy Practices Acceptance *

I have read and agree to the Notice of Privacy Practices

Patient Name *

First

Last

Parent of Authorized Representitive (if applicable)

First

Last

Signature *

Clear Signature

Date Signed *

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Release of Medical Information

I authorize the release of medical information / test results to the following person(s) other than myself.

Name 1

Relationship 1

Phone 1

Name 2

Relationship 2

Phone 2

Name 3

Relationship 3

Phone 3

Medical Release Acceptance *

I authorize Squire Foot and Ankle PLLC to leave information / test results on my voice mail and / or answering machine at the contact numbers provided above.

Signature *

Clear Signature

Date Signed *

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Patient Financial Responsibity

Assignment of Benefits and Financial Responsibility: I authorize the above listed medical practice and its’ agent(s) to contact my insurance provider to verify my eligibility for insurance coverage. I authorize the release of information necessary to process this claim and hereby assign my insurance benefits be paid directly to Chad A. Squire DPM, FACFAS and Squire Foot and Ankle, PLLC. I acknowledge that I am responsible for paying all deductibles, co-payments, coinsurance amounts and any portion of non-covered services not paid by my insurance company or government benefit program. Such payments are due at time of service or immediately upon presentation of a bill. I understand that failure to fulfill my financial obligations may result in collection efforts if my account is considered significantly delinquent and all efforts to collect directly by the Squire Foot and Ankle, PLLC and its’ agent(s) have been exhausted.

Patient Financial Responsibity Acceptance *

I have read and accept the Patient Financial Responsibity policy outlined above.

Signature

Clear Signature

Date Signed

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New Patient Registration Form

New Patient Registration Form

Basic Information

Emergancy Contact

Patient Contact Information

Employment Information

Basic Medical Information

Responsible Party Information

Insurance Information

Chief Complaint

Review of Symptoms

Social History

Other Personal Information

Acknowledgement of Receipt of Notice of Privacy Practices

Release of Medical Information

Patient Financial Responsibity

Why live in pain?

Squire foot and Ankle