Medical Employment Information Form

New Patient Information Record
Name*

First NameLast Name
Birth Date*

MonthDayYear
Age
Phone Number*

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Social Security#
Occupation
Work or Cell #

Area CodePhone Number
E-mail Address
example@example.com
Shoe Size
Marital Status

SingleMarriedDivorcedWidowed
Name of Spouse / Guardian
Phone #

Area CodePhone Number
Billing Information: (Please provide the receptionist with insurance cards for scanning)
Primary Insurance
Secondary Insurance
If other than patient, enter the name and address of person responsible for this account:
Whom may we thank for referring you to us:
Medical History
Primary Foot Complaint
For how long?
List of Medications
Allergies to Medications
Symptoms? (i.e., upset stomach, difficulty breathing)
Primary Physician
Date of last visit

MonthDayYear
Date
Former Podiatrist
Treatment for
Please select if you have the following:
Bunions

YesNo
Alcohol Abuse

YesNo
Gout

YesNo
Corn/Calluses

YesNo
Anemia

YesNo
Heart Disease

YesNo
Circulation Problems

YesNo
Arthritis

YesNo
High Blood Pressure

YesNo
Foot/Leg Cramps

YesNo
Blood Clotting

YesNo
Kidney Disease

YesNo
Foot/Leg Numbness

YesNo
Cancer

YesNo
Liver Disease

YesNo
Painful Toes

YesNo
Cigarette Use

YesNo
Lung Disease

YesNo
Toenail Problems

YesNo
Diabetes I or 2

YesNo
Stomach Ulcers

YesNo
I hereby give Vallejo Foot & Ankle Clinic (VFAC) permission to render examination and treatment of my foot conditions. I request that payment of medical benefits be made to VFAC on my behalf for any services furnished to me. I authorize the release of medical information to those agents requesting any information needed to determine these benefits payable for related services. Furthermore, I realize that by signing this form, I agree to pay for any services rendered that are denied or not covered by my insurance company.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

New Patient Information Record

Medical History