absolutefootandankleclinic.com-PODIATRIST FIRST VISIT

ABSOLUTE MEDICAL CARE/ ABSOLUTE FOOT AND ANKLE CLINIC

PODIATRIST FIRST VISIT FORM
Date

MonthDayYear
Patient Full Name

First NameLast Name
Date of Birth

MonthDayYear
Sex
SSN
Email Address
example@example.com
Patient Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Race / Ethnicity

American Indian or Alaska NativeAsianBlack or African AmericanHispanic or LatinoNative Hawaiian or Other Pacific IslanderWhiteOther
Preferred Language
Patient Home Phone
Cell
Emergency Contact Name

First NameLast Name
Relationship
Phone Number

Area CodePhone Number
Family Doctor’s Name

First NameLast Name
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Last Visit Date

MonthDayYear
Chief Complaint (reason for seeing a Podiatrist)
Have you ever been to a Podiatrist Before

YesNo
If Yes, please list: Name
Date of Last Visit

MonthDayYear
Is there any personal of family history of diabetes?

YesNo
Your occupation
Cigarette/ Tobacco Use

YesNo
Years Smoked
Athletic activities in which you participate (please list and indicate frequency)
Please check the box to indicate if you have had any of the following:

AIDS/HIVAllergies to AnestheticsAllergies to Medicine/DrugsAnemiaAnginaArthritisArtificial Heart Valves or JointsAsthmaBack ProblemsBleeding DisordersCancerChemical DependencyChest PainChronic DiarrheaCirculatory ProblemsDiabetesEar ProblemsEpilepsyEye ProblemsFaintingFoot or Leg CrampsGoutHeadachesHeart DiseaseHemophiliaHepatitis or JaundiceHigh Blood PressureKidney ProblemsLiver DiseaseLow Blood PressureNeuropathyPhlebitisPsychiatric CareRadiation TreatmentRashRespiratory DiseaseRheumatic FeverShortness of BreathSinus ProblemsSpecial DietStrokeSwelling of Ankles, FeetSwollen Neck GlandsTired FeetTuberculosisUlcersVaricose VeinsVenereal DiseaseWeight loss unexplainedTaking Contraceptives
PREVIOUS SURGERIES / HOSPITALIZATIONS
MEDICATIONS
Include prescriptions, over-the-counter medications and vitamins (bring in a list if present)
Pharmacy Name(s)
Pharmacy Phone(s)
ALLERGIES ( Check the box if you have had allergies from any of the following)

Adhesive / TapeAspirinCodeineIodineDemerolLocal AnestheticsAnticoagulant TherapyNovocainePenicillinSeafoodSulfaOther
INSURANCE INFORMATION
(Please have all Insurance Cards and Id with you during visit)
Insured Name

First NameLast Name
Primary Insurance Company Name
Insurance ID#
Group #
Claims Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
SUPPLEMENTAL/ SECONDARY INSURANCE
Insured Name

First NameLast Name
Insurance Company Name
Insurance ID#
Group#
Claims Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PATIENT CONSENT FOR TREATMENT
I, Namehereby give my permission to Dr. Rabinovich D.P.M. and his staff and associates to administer treatment and perform such procedures as may be deemed necessary in the diagnosis and/or treatment of my foot-ankle condition(s)
AUTHORIZATION TO RELEASE INFORMATION
I, Namehereby authorize Dr. Rabinovich to release any medical information pertaining to my treatment and permit any insurer to inspect my medical records in connection with charges arising from this treatment in accordance with Health Insurance Portability and Accountability Act of 1996 (HIPAA) and all its provisions. I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action relying on this consent.
FINANCIAL POLICY
I, Name hereby authorize payment of medical benefits to Dr. Rabinovich for services rendered by him in person or under his supervision. I understand that I am financially responsible for any balance not covered by my insurance, including co-pays, deductible, and non-covered services if any. If you do not have insurance, the total agreed upon with the doctor cost of your visit is required at the time of service. If you have a high deductible plan (over $500) with unmet deductible or you are receiving a non-covered service/procedure, a deposit payment will be required at time of service at office cash price fee schedule for procedures/DME received. Missed appointment fee is $40. Should you default on your required payment, collection action is possible.
I have read and accept the financial policy of Absolute Medical Care &Absolute Foot and Ankle Clinic. I authorize payment of medical benefits to the named provider for professional services rendered.
Signature of Adult over 18

Clear
Patient Name

First NameLast Name
Relationship to Patient
Date

MonthDayYear
Signature

Clear
Absolute Foot and Ankle Clinic 3546 N. Milwaukee Ave. Northbrook Il 60062 847-297-9660

Absolute Medical Care 20637 W. Renwick Rd Crest Hill Il 60403 815-838-9505
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