Complete New Patient Forms

Dr. Matthew F. Wachtler, DPM, FACFAS

882 Pompton Ave, Suite B-1, Cedar Grove, NJ 07009 (p) 973-857-1184 (f) 973-857-3114
Name*

First NameLast Name
Today's Date*

MonthDayYear
Date
Date of Birth*
Month/Day/Year
Social Security Number
Email
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Primary Care Doctor
Pharmacy Name / Location
Reason For Visit*
Height / Weight
Ft, in. / lbs
Allergies*
Medications*
Past Medical History*
(examples: High Blood Pressure, High Cholesterol, Diabetes, Heart Disease, Liver Disease, Kidney Disease, Hepatitis, HIV, Thyroid disorder, any other medical conditions......)
Past Surgical History*
Family Medical History - Father*
(Cancer, Heart Disease, Diabetes, or other medical conditions)
Family Medical History - Mother*
(Cancer, Heart Disease, Diabetes, or other medical conditions)
Family Medical History - Brother*
(Cancer, Heart Disease, Diabetes, or other medical conditions)
Family Medical History - Sister*
(Cancer, Heart Disease, Diabetes, or other medical conditions)
Family Medical History - Other
(Cancer, Heart Disease, Diabetes, or other medical conditions)
Tobacco/Smoking Status*

NeverFormer Smoker/Tobacco UseCurrent Smoker/Tobacco Use
Alcohol Use

NeverOccasional/LightDaily
Current Flu Vaccine

YesNo
Current Pneuomnia Vaccine (>65 yrs old)

YesNoN/A
Advanced Directive (>65 yrs old)

YesNoN/A
Marital Status

SingleMarriedDivorcedWidowedDECLINE
How did you hear about our office?

FriendInsuranceInternetDoctor ReferralOther
Emergency Contact
Name / Contact Number
Signature - Medical History Form*

Clear
HIPAA Consent Form

I understand that under the Health Portability and Accountability Act 1996 (HIPAA) I have certain rights to privacy regarding my health information. I also understand that Cedar Grove Foot & Ankle Specialists originates and maintains paper and/or electronic records describing my health history, symptoms, examinations, test results, diagnoses, treatments and any plans for future care and treatment at Cedar Grove Foot & Ankle Specialists. I understand that this information can be used as:
- A basis for planning my care and treatment and followup among multiple healthcare providers who may be involved in that treatment directly or indirectly.
- A means of communication amoung the many healthy professionals who contribute to my care
- A means by which a 3rd party can verify that services billed were actually provided and obtain payment from 3rd party payers
- A tool for routine healthcare operations such as assessing quality and receiving the competence of healthcare professionals
My Health information may also be discussed with the following people upon their request:
Name / Relationship
I prefer to have notification of my healthcare information by the following methods. Please check all application

Home/Cell PhoneWork PhoneIf I am not available, you may leave a message with a family memberDetailed message on answering machine
Name*

First NameLast Name
Date*

MonthDayYear
Date
Signature - Received HIPAA Consent Form*

Clear
Notice of Privacy Practices

Acknowledgement of Receipt

I acknowledge that I was provided an opportunity to read (if I chose to), a copy of the notice of Privacy Practices and understood the notice.
Name*

First NameLast Name
Date*

MonthDayYear
Date
Signature - Notice of Privacy Practices Receipt*

Clear
Insurance Information
Primary Insurance Company and Policy Number / Group Number*
Insurance Company and Policy Number
Secondary Insurance Company and Policy Number / Group Number
Policy Holder Name and Relation*
Policy Holder Name and Relation: Self / Spouse / Child
Policy Holder SSN
Policy Holder DOB and Gender*
Financial Responsibility / Insurance Benefits / Notice of Collection Action

I understand that I am responsible for knowing the benefits of my insurance plan. In doing so, it is my responsibility to verify proof of insurance by ensuring that the office has the most current/valid insurance on file. I understand that all co-payments are due at the time of service and I am also responsible to pay other amounts due; these amounts may include deductibles, coinsurances, charges denied by my insurance as not covered or not medically necessary and/or any fees incurred should my account require collection action (late fees, collection agency, court or attorney fees). Also, I understand that on occasion, the office may contact my insurance to obtain benefit information as a courtesy to me, however the information obtained from the insurance company is not a guarantee of payment, which may still result in my responsibility.
Signature - Financial Responsibility / Insurance Benefits / Notice of Collection Action*

Clear
Front of Insurance Card (Take Picture or Upload)*

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Back of Insurance Card (Take Picture or Upload)

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Drivers License (Take Picture or Upload)

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Should be Empty:

Dr. Matthew F. Wachtler, DPM, FACFAS

Insurance Information