Patient Paperwork

1
What is Todays Date? * This field is required.¿Cuál es la fecha de hoy?
Date (Fecha)
Month
Day
Year
2
Please Type Your Name* This field is required.¿Cuál es su nombre?
First Name (Primer nombre)
Middle Name (Segundo nombre)
Last Name (Apellido)
Suffix (Sufijo)
3
What is Your Date of Birth?* This field is required.¿Cuál es su fecha de nacimiento?
use month/day/year format (Usar el formato mes/día/año)
4
What is your age?¿Cuál es su edad?
5
What is Your Social Security Number?* This field is required.¿Cuál es su número de Seguridad Social?
6
What Is Your Gender?* This field is required.¿Cuál es su género?
Female (Mujer)
Male (Hombre)
Other (Otro)
7
Please Enter Your Preferred Name, Pronoun and How You Would Like to be Addressed:Por favor ingrese su nombre preferido, pronombre y cómo le gustaría que se dirigiera a usted:
8
Please Enter Your Email:Por favor ingrese su correo electrónico:
example@example.com (ejemplo@ejemplo.com)
9
Please Enter Your Address* This field is required.Por favor escriba su dirección
Street Address (La dirección)
Street Address Line 2 (La dirección adicional)
City (Ciudad)
State / Province (Estado/Provincia)
Postal / Zip Code (Código Postal)
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
10
How Can We Contact You?Enter numbers only. Do not add -, ( ), or spaces. ¿Cómo podemos ponernos en contacto con usted? Por favor de escribir sólo números, no agregar -,(), o espacios.
Please enter your primary phone number (Por favor, escriba su número de teléfono principal)
Please enter your work phone number (Por favor, escriba su número de teléfono del trabajo)
Please enter a secondary phone number (Por favor, escriba su número de teléfono secundario)
11
Which Number Should We Use For Reminder Calls* This field is required.¿Qué número podemos usar para recordarle?
Cell Phone Number (El número de teléfono celular)
Home Phone Number (El número de teléfono de hogar)
Work Phone Number (El número de teléfono de trabajo)
12
Have you been diagnosed as diabetic?* This field is required.¿Le han diagnosticado diabetes?
YES (Sí)NO
13
What is Your Marital Status?¿Cuál es su estado civil?
Single (Soltero/a)
Divorced (Divorciado/a)
Widowed (Viudo/a)
Separated (Separado/a)
Married (Casado/a)
Other (Otro)
14
What is Your Primary Language?* This field is required.¿Cuál es su idioma principal?
English (Inglés)
Spanish (Español)
Other (Otro)
15
What Is Your Employment Status?¿Cuál es su estatus laboral?
Full-Time (Tiempo completo)
Part-Time (Medio Tiempo)
Unemployed (Desempleado)
Retired (Jubilado)
16
Who Is Your Employer?¿Quién es su empleador?
17
What Is Your Occupation?¿Cuál es su ocupación?
18
If You Were Referred To Us, Who Was Your Referring Doctor?Si fue referido a nosotros, ¿quién fue su médico de referencia?
19
What Is The Name and Phone Number Of Your Primary Doctor?¿Cuál es el nombre y el número de teléfono de su médico primario?
20
What Is Your Pharmacy Name and Location?¿Cuál es el nombre y la ubicación de su farmacia?
21
How Did You Hear About Us? (Check All That Apply)¿Cómo se enteró de nosotros? (Marque todo lo que corresponda)
Friend/Family (Amigo/Familia)
Doctor (Médico)
Insurance (Seguro médico)
Internet
Facebook
Phone Book (Guía telefónica)
Walk In/Drive By (Entrar o conducir por)
Other
22
Spouse/Parent/Guardian Information: What is the name of your spouse, parent, or guardian? (¿Cuál es el nombre de su cónyuge, padre o tutor?)
23
Birth Date (Fecha de nacimiento)What is the date of birth of your spouse, parent, or guardian? (¿Cuál es la fecha de nacimiento de su cónyuge, padre o tutor?)
use month/day/year format (Usar formato mes/dia/año)
24
Phone Number (Número de teléfono)What is the phone number of your spouse, parent, or guardian? (¿Cuál es el número de teléfono de su cónyuge, padre o tutor?)
Please enter a valid phone number. (Por favor escriba un número de teléfono válido.)
25
Who is Your Emergency Contact?¿Quién es su contacto de emergencia?
26
Phone NumberWhat is the phone number of your emergency contact? (¿Cuál es el número de teléfono de su contacto de emergencia?)
Please enter a valid phone number. (Por favor escriba un número de teléfono válido.)
27
If Patient is a Minor, Who Can Make Medical Decisions?Please Enter Name, Relationship to Patient, and their Phone Number: (Si el paciente es menor de edad, ¿quién puede tomar decisiones médicas? Por favor escriba el nombre, relación con el paciente, y número de teléfono.)
28
Photography to document patient care* This field is required.I understand that Dr Bean, or his staff, may take photographs of my foot to document my care and the process of healing. I understand that Dr Bean will retain ownership rights to these images, but that I will be allowed access to view them or obtain copies. I understand that these images will be stored in my electronic chart in a secure manner that will protect my privacy and that they will be kept for the time period required by law. These images will not be used for any other purposes unless Dr. Bean first obtains my written permission.
Type name
29
Photography and Videos by Patients * This field is required.Patients, or their family and friends, may only take pictures in the exam room at the beginning of a procedure and/or at the end of a procedure. Photography is not allowed during the time the Doctor or his staff are treating the patient. No videos may be taken at anytime.
Type name
30
Medical Records ReleaseI give permission to release my medical records to the following persons or those directly related to my medical care: (Liberación de registros médicos: Doy permiso para divulgar mis registros médicos a las siguientes personas o directamente relacionadas con mi atención médica: Por favor escriba el nombre, la dirección y el número de teléfono del médico/persona/instalación/entidad.)
Please enter the name, address, and phone number of the physician/person/facility/entity.
Please enter the name, address, and phone number of the physician/person/facility/entity.
Please enter the name, address, and phone number of the physician/person/facility/entity.
31
Medical Records Release: By initialing this form, I authorize you to give confidential health information about me, by releasing a copy of my medical records, a summary of care, or a narrative of my protected health information, to the physician/person/facility/entity listed above.Liberación de Registros Médicos: Al iniciar este formulario, le autorizo a dar información confidencial de salud sobre mí, mediante la liberación de una copia de mis registros médicos, un resumen de la atención, o una narrativa de mi información de salud protegida, al médico / persona / centro / entidad enumerada anteriormente.
32
What is the name of your Primary and Secondary Insurance?* This field is required.¿Cuál es el nombre de su seguro médico primario y secundario? Escriba "pago por cuenta propia" si no tiene seguro.
Please Enter the Name and Member ID# of your Primary Insurance. Enter "self-pay" if you are uninsured.
Please Enter the Name and Member ID # of your Secondary Insurance. Enter "none" if you don't have Secondary Insurance.
33
Insurance Benefits* This field is required.Read each statement and click each box
I have reviewed and understand my insurance plan, co-pay, co-insurance, deductible, and/or benefits.
If I need a referral to be seen by a specialist I will obtain a referral from my PCP and make sure it is delivered to Sierra Podiatry Center.
I understand that I am to know if a prior authorization is needed before my office visit. I agree to pay for charges incurred due to failure to obtain a prior authorization.
I have reviewed my provider directory. The provider I am seeing today is listed as a contracted provider.
I understand that all procedures and biopsies are subject to deductibles and/or co-pays as deemed by my insurance company.
SPC is contractually obligated to collect all co-pays, co-insurances, and deductibles as deemed by my insurance company at each office visit. I understand that I am responsible for the amount of money that my insurance company says I owe for a service processed by my insurance company.
I understand that even though authorization may be obtained from my insurance company, they may still deny coverage once the claim is processed. If this occurs, I am still responsible for paying charges regardless of what the explanation of benefits may state.
34
Insurance Information* This field is required.Read each statement and click each box
I have provided Sierra Podiatry Center/ Sierra Center for Foot Surgery with my complete medical insurance information. This medical insurance is active, current, and all premiums are paid up to and beyond the date of service.
I do hereby attest that this information is true, accurate and complete to the best of my knowledge. I understand that any falsification, omission or concealment of any material fact may subject me to all fees for services and/or other liability.
I also understand that I am to notify Sierra Podiatry Center/Sierra Center for Foot Surgery immediately of any changes to the above information and annually upon the office’s request.
I hereby authorize payment of my health insurance benefits directly to Sierra Podiatry Center/Sierra Center for Foot Surgery and Jeffrey K. Bean, DPM. I also authorize them and their representatives to submit claims for medical insurance benefits, inquire about eligibility and benefits, appeal or dispute claims decisions and request hearings, and to represent me in these actions.
I authorize them to release medical and identifying information for the above purposes. I agree to pay all deductibles and co-pays at the time of service. I understand that payment for all services is ultimately my responsibility.
35
Privacy Notice: I acknowledge that I have been provided with a copy of the Notice of Privacy Practices and Patient Rights and that I have read or have had the opportunity to read it, if I so chose to. I understand the Notice. Copies of the Notice of Privacy Practices and Patient Rights can be found in the patient reception area of Sierra Podiatry Center and on our website at sierrapodiatry.com on the Patient Privacy page.* This field is required.Aviso de Privacidad: Reconozco que se me ha proporcionado una copia del Aviso de Prácticas de Privacidad y Derechos del Paciente y que he leído o he tenido la oportunidad de leerlo, si así lo he elegido. Entiendo el Aviso. Se pueden encontrar copias del Aviso de Prácticas de Privacidad y Derechos del Paciente en el área de recepción de pacientes del Centro de Podología Sierra y en nuestro sitio web en sierrapodiatry.com en la página de Privacidad del Paciente.
Type Initials (Escriba iniciales)
36
List all the foot/ankle issues you would like to address with the doctor at your appointment.* This field is required.¿Cuál es el motivo de su visita con nosotros hoy?
37
Have you received any previous treatments for your current foot problem? Yes or No? Please explain:* This field is required.¿Ha recibido algún tratamiento previo para su problema actual en el pie? ¿Sí o no? Por favor, explique:
38
Earliest date that you noticed the condition you are being seen for:Fecha más temprana en que notó la afección por la que lo están viendo:
Date (Fecha)
Month
Day
Year
39
Does this condition involve a worker's comp claim?* This field is required.¿Esta condición implica un reclamo de compensación laboral?
YES (SI)NO
40
Was this condition caused by an injury?* This field is required.¿Esta condición fue causada por una lesión?
YES (SI)NO
41
What is the location of the current problem? (Left Foot)Check all that apply: ¿Cuál es la ubicación del problema actual? (pie izquierdo) Marque todas las que apliquen:
Toenails (Uñas del pie)
Big Toe (Dedo gordo)
Other Toes (Otros dedos del pie)
Ball of Foot (Bola del pie)
Arch (Arco del pie)
Heel (Tacón de pie)
Instep (Empeine del pie)
Top of Foot (Parte superior del pie)
Ankle (El tobillo)
Calf (La pantorilla)
Leg (La pierna)
Achilles Tendon (El tendón de Aquiles)
Other (Otro)
42
What is the location of the current problem? (Right Foot)Check all that apply: ¿Cuál es la ubicación del problema actual? (pie izquierdo) Marque todas las que apliquen:
Toenails (Uñas del pie)
Big Toe (Dedo gordo)
Other Toes (Otros dedos del pie)
Ball of Foot (Bola del pie)
Arch (Arco del pie)
Heel (Tacón de pie)
Instep (Empeine del pie)
Top of Foot (Parte superior del pie)
Ankle (El tobillo)
Calf (La pantorilla)
Leg (La pierna)
Achilles Tendon (El tendón de Aquiles)
Other (Otro)
43
What is your level of pain?(0 = No Pain, 10 = Worst Pain): ¿Cuál es su nivel de dolor? (0 = sin dolor, 10 = peor dolor):
0
1
2
3
4
5
6
7
8
9
10
Not Applicable (No corresponde)
44
Is your pain...Está su dolor...
Improving (Mejorando)
Worsening (Empeorando)
Not Changing (No a cambiado)
Not Applicable (No corresponde)
45
What type of pain are you experiencing?* This field is required.(Check all that apply:) ¿Qué tipo de dolor estás experimentando? Marque todas las que apliquen:
Aching (Adolorido)
Bruised (Magullado)
Burning (Con ardor)
Cramping (Con calambre)
Deep (Dolor profundo)
Dull (Dolor ligero)
Inflamed (Inflamado)
Itchy (Con picazón)
Numb (Entumido)
Pressure (Con presión)
Sharp (Dolor punzante/agudo)
Swollen (Hinchado)
Tender (Tierno)
Tight (Tenso)
Tingling (Sensación de hormigueo)
Other (Otro)
Not Applicable (No corresponde)
46
How often do you experience pain?* This field is required.¿Con qué frecuencia experimenta el dolor?
At Night (Por la noche)
Constant (Constante)
In A.M. (Por la mañana)
Off and On (De vez en cuando)
Rarely (Raramente)
First Steps After Rest (Primeros pasos después del descanso)
At Rest (Al descansar)
When Standing or Walking (Al pararse o caminar)
Not Applicable (No corresponde)
Other
47
What makes the pain feel better?* This field is required.¿Qué hace que el dolor mejore?
Increased Activity (Aumento en actividad)
Certain Shoes (Ciertos zapatos)
No Shoes (Sin zapatos)
Pressure (Aplicación de presión)
Rest (Al descansar)
Running (Corriendo)
Standing (De pie)
Walking (Caminando)
Other (Otro)
Not Applicable (No corresponde)
48
What makes the pain feel worse?* This field is required.¿Qué empeora el dolor?
Increased Activity (Aumento en actividad)
Certain Shoes (Ciertos Zapatos)
No Shoes (Sin zapatos)
Pressure (Aplicación de presión)
Rest (Al descansar)
Running (Corriendo)
Standing (De pie)
Walking (Al caminar)
Other (Otro)
Not Applicable (No corresponde)
49
Specific Foot Problems:* This field is required.(Check all that apply:) Problemas específicos de los pies, marque todos que apliquen:
Bunions (Juanetes)
Heel Pain (Dolor en el talón)
Arch Pain (Dolor en el arco del pie)
Hammer Toes (Dedos de martillo)
Ingrown Toenails (Uñas enterradas)
Toenail Problems (Problemas de uñas de los pies)
Other Toe Problem (Otros problemas en los dedos de los pies)
Flat Feet (Pies planos)
Calluses/Corns (Callos)
Ankle Sprain (Esguince de tobillo)
Nerve Pain (Dolor nervioso)
Skin Problems (Problemas de la piel)
Wound or Ulcer (Heridas/úlceras)
Warts/Lesions (Verrugas/lesiones)
Other (Otro)
50
Previous Foot Problems/Procedures* This field is required.(Check all that apply:) Problemas/procedimientos previos en los pies, marque todos que apliquen:
None (Ninguno)
Bunion (Juanete)
Hammer Toe (Dedo de martillo)
Ingrown Toenail (Uña enterrada)
Toenail Fungus (Hongo de las uñas de los pies)
Amputation (Amputación)
Other
51
Biometrics Please enter your weight, height and shoe size. Datos demográficos, por favor escriba su peso, estatura, y talla de zapatos:
Weight (Peso)
Height (Estatura)
Shoe Size (Talla de zapatos)
52
Allergies:* This field is required.(Check all that apply:) Alergias, marque todos que apliquen:
Penicillin (Penicilina)
Sulfa Drugs (Sulfamidas)
Aspirin (Aspirina)
Codeine (Codeína)
Morphine (Morfina)
Adhesive Tape (Cinta adhesiva)
Latex (Látex)
Chemicals (Sustancias químicas)
Dairy (Los lácteos)
Eggs (Huevos)
Gluten
No Known Allergies (Sin alergias conocidas)
Other
53
List any other allergies that were not included in the previous screen:Escriba cualquier otra alergia que no se incluyó en la pantalla anterior:
54
Do you use tobacco?* This field is required.¿Usas tabacco?
YES (SI)NO
55
If you answered "yes" to using tobacco, list how much, for how long, and what type. (Vape, cigar, cigarettes, chewing tobacco)Si respondió "sí" al consumo de tabaco, haga una lista de cuánto, por cuánto tiempo y de qué tipo. (Vape, cigarro, cigarrillos, tabaco de mascar)
56
Do you drink alcohol? If yes, how many drinks do you consume in a week?¿Bebe alcohol? En caso afirmativo, ¿cuántas bebidas consumes en una semana?
57
Do you use recreational drugs?* This field is required.¿Usa drogas recreacionales?
YES (SI)NO
58
Have you had any previous surgeries?(Check All That Apply): ¿Ha tenido alguna cirugía previa? Marque todas que apliquen:
None (Ninguna)
Angioplasty/Stent (Angioplastia/Stent)
Appendectomy (Apendectomía)
Back/Spine Surgery (Cirugía de columna vertebral)
Cesarean Section (Cesárea)
Defibrillator (Desfibrilador)
Gallbladder Surgery (Cirugía de la vesícula biliar)
Gastric Bypass (Bypass gástrico)
Heart Bypass (Bypass cardíaco)
Heart Valve Replacement (Reemplazo de válvulas cardíacas)
Hysterectomy (Histerectomía)
Joint Replacement (Reemplazo de articulaciones)
Lap Band (Banda gástrica)
Lower Extremity Bypass (Bypass de las extremidades inferiores)
Pacemaker (Marcapasos)
Tonsillectomy (Amigdalectomia)
Transplant (Transplante)
Other. Please explain on next screen. (Otro, por favor escriba en la próxima pantalla.)
59
Other SurgeriesPlease list here. (Otras cirugías, por favor escriba aquí.)
60
Medical Conditions* This field is required.(Treated and Untreated- Check All That Apply. Scroll down to see complete list): Condiciones médicas, (tratadas y no tratadas- marque todas las que correspondan. Desplácese hacia abajo para ver la lista completa)
None (Ninguna)
Anxiety (Ansiedad)
Arthritis (Artritis)
Asthma (Asma)
Bleeding Disorder (Trastorno hemorrágico)
Blood Clots (Coágulos de sangre)
Cancer (Cáncer)
Chemotherapy (Quimioterapia)
Circulation Problems (Problemas de circulación)
Depression (Depresión)
Diabetes (Diabetes)
Fibromyalgia (fibromialgia)
Foot Ulceration(s) (Ulceraciones del pie)
Gout (Gota)
Heart Attack (Ataque al corazón)
Heart Disease (Cardiopatía)
Hepatitis (Clarify type at appt) (Hepatitis)
High Blood Pressure (Presión alta)
Kidney Disease (Enfermedad renal)
Liver Disease (Enfermedad hepática)
Lung Disease (Enfermedad pulmonar)
Lupus (Lupus)
Neuropathy (Neuropatía)
MRSA Infection (Infección por mrsa)
Osteoporosis
Pain in Legs/Feet/Toes (Dolor en las piernas/pies/dedos del pie.)
RSD/CRPS
Seizure Disorder (Trastorno convulsivo)
Sleep Apnea (Apnea del sueño.)
Sports-Related Injury (Lesiones relacionadas con el deporte.)
Stomach Ulcer (úlcera estomacal)
Stroke (Apoplejía)
Swelling in Legs/Feet (Hinchazón en piernas/pies)
Thyroid Disorder (Trastorno de la tiroides)
Other. Please list on next screen. (Otro, por favor esciba en la pantalla siguiente.)
61
Other Medical ConditionsPlease list here. (Otras condiciones médicas, por favor escriba aquí.)
62
What is your family history?* This field is required.(Check All That Apply: History of Parents, Siblings, Children) Cuál es su historia familiar, marque todos que apliquen. Historia de padres, hermanos, hijos.)
Allergies (Alergia)
Arthritis (Artritis)
Cancer (Cáncer)
Diabetes
Gout (Gota)
Heart Attack (Ataque al corazón)
High Blood Pressure (Presión alta)
Kidney Problems (Problemas renales)
Liver Problems (Problemas del hígado)
Lung Disease (Enfermedad pulmonar)
Mental Illness (Enfermedades mentales)
Other (Otro)
None (Ninguno)
63
Please list all medications/vitamins/minerals/herbs/supplements/over the counter products: (enter none or NA if you don't take any of the above)* This field is required.Por favor escriba todos los medicamentos/vitaminas/minerales/hierbas/supplementos/y otros productos que tome:
64
By submitting this new patient paperwork to Sierra Podiatry Center and signing my name, I signify that I am in agreement with the following TERMS AND CONDITIONS* This field is required. ~Please bring your insurance cards, driver’s license or ID, and a list of all medications that you are currently taking (if not listed in the previous screen) ~If you require assistance, please bring someone with you who can help. This person must stay with you during your entire appointment. ~We understand that situations arise when you may be unable to keep a scheduled appointment. Please be courteous and call to cancel or reschedule. If a 24-hour business day notice is not given for a missed or rescheduled appointment, you will be charged a $100.00 fee for an office visit and a $200.00 fee for an office procedure. These fees are not covered by insurance. ~If you require leave of absence paperwork or any work-related forms to be completed by Dr Bean, there will be a fee of $35.00. Please allow 3-5 business days for completion. ~Repetitive broken appointments, non-compliance, hostile behavior and/or financially deficient accounts will result in appointment hold and/or termination of our Doctor-Patient relationship. Thirty (30) days’ advance notice will be given should the situation result in a transfer of the patient’s care. ~If you have a balance with us after your insurance has paid or has denied payment for any reason, you are responsible for and required to pay the balance, in full, within 30 days of your first statement. Please contact us immediately if payment arrangements are needed. If you have not contacted us to make payment arrangements, your account will be referred to a collection agency after two statements have been sent out. If your account is referred to a collection agency, your balance will be increased by an additional 50% for processing.
Clear
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Before you submit....*Once you click "Submit" you will not be able to change any of your information through this format, but it can be corrected at the time of your visit. Use the "Review and Submit" option to make any needed changes and then click "Submit" when ready. *Thank you for your time and trusting us with your care. We look forwarded to seeing you at your upcoming appointment. *If you have any feedback on the new patient questionnaire please list in the box below. (*Una vez que haga clic en “Enviar”, no podrá cambiar su información a través de este formato, pero puede corregirse en el momento de su visita. Utilice la opción Revisar y enviar para realizar los cambios necesarios y, a continuación, haga clic en Enviar cuando esté listo. *Gracias por su tiempo y confiar en nosotros con su cuidado. Esperamos verle en su próxima cita. *Si tiene algún comentario sobre el nuevo cuestionario para el paciente, por favor haga una lista en el cuadro de abajo.)
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