TOTAL FOOT AND ANKLE CARE, PLLC

What brings you to the office today

Patient’s Name *

First NameLast Name

DOB*

Date

Have you ever had surgery or injury in the past?*

YesNo

Please list all surgeries and injuries

Is your visit related to an injury at work?*

YesNo

Please explain

Is your visit related to a car accident?*

YesNo

Please explain

Are you allergic to any medication or food?

YesNo

Please list the name of the medication or the food

Are you diabetic?

YesNo

Do you

Use insulin?Take tablets?

Do you have or had any of the following medical conditions

	Yes	No
Alcoholism Pregnant
Allergies
Alcoholism
Alzheimer's
Anemia Smoke
Anxiety Low Blood Pressure
Arthritis
Asthma
AIDS/HIV
Bleeding Disorder/ Blood Disorder
Cancer
Diabetes
Epilepsy Osteoporosis
Hepatitis
Heart Attack/ Heart Disease/Irregular Heart Rate
High Cholesterol Levels
High Blood Pressure Pacemaker
Kidney Disease
Liver Disorder
Lung Disease/ Tuberculosis
Osteoporosis
Psychiatric Disorders
Substance Abuse
Swelling of Foot or Ankle
Stomach Problems/ Ulcers
Stroke
Varicose Veins
Artificial Joints
Circulatory Problems
Rheumatoid Arthritis /Lupus
Thyroid Problem
Pacemaker

Do you have or had any other diseases or medical problem NOT listed on this form?

YesNo

Please list other diseases or medical problems

To the best of my knowledge, I have answered every question completely and accurately. I will inform my podiatrist of any changes in my health.

Signature*

Date*

Date

Insurance company name*

Patient’s name*

First NameLast Name

I request that the payment of authorized {insuranceCompany} (Insurance companyname, e.g. Medicare, etc), be made to Christopher Chow DPM, PC on my behalf for the service furbished to me by the provider. I authorized any holder of medical information about me to release to {insuranceCompany} (Insurance company
name) and other information needed to determine thesebenefits of the benefits payable for the related service.

And

I, {patientsName126} (Patient’s name) declare the condition(s) or the disease(s), which I came to see Total Foot and Ankle Care, is not related to motor vehicle accident or work related injury which should be covered by no fault or worker’s compensation insurances. I understand that State Law
Penal Code, section 176.05 requires us to inform you that any person who knowingly and with intent to defraud any insurance company, physician or other health practitioner, files an application for insurance or statement of the claims and counterclaiming any materially false informationor conceals, for the
purposeof misleading, information concerning anymaterial fact there in, commits a fraudulent act, which is a crime. Such acts are subject to a civilpenalty notto exceed $5000 and the stated value of the claim for each violation.

The misrepresentation of health benefits including providing false information about coverage, or not disclosing all available health benefits is considered a fraudulent act. The formation you present is your representations, and you are responsible for their accuracy.

It is the policy of this office to report all suspected insurance fraud, including misrepresentations of insurance coverage to the New York State commissioner of insurance, insurance Fraud Bureau.

This Consent was signed by:

Patient Name (Print)*

First NameLast Name

Signature*

Date*

Date