New Patient Form
Note: if you'd like to download a printable PDF instead of filling out the online form, please click here.
The physicians at Signature Foot & Ankle are concerned about your overall health and wellbeing and are evaluating factors in which may impact your overall health and orthopedic health. The following questions are intended to give the physicians information about your general health.
To the best of my knowledge, I have answered the questions on this form accurately. I understand that providing incorrect or incomplete information can be dangerous to my health. I understand that it is my responsibility to inform the doctor and office staff of any changes in my medical status. Parent or legal guardian name and signature required for individuals under age 18.
I understand that photographs, videotapes, digital, or other images may be recorded to document my care, and I consent to this. I understand that Signature Foot and Ankle will retain ownership rights to these photographs, videotapes, digital, or other images, but that I will be allowed access to view them or obtain copies. I understand that these images will be stored in a secure manner that will protect my privacy and that they will be kept for the time period required by law or outlined in Signature Foot and Ankle’s policy. Images that identify me will be released and/or used outside the institution only upon written authorization from me or my legal representative.
I give my consent to have photographs, videotaped images, or other images made during the visit. I understand and agree that these images may be used by Signature Foot and Ankle for the purpose outlined below. They will not include any identifiable features when used outside of my chart. This includes, but is not limited to: Teaching purposes, which includes being shown to other patients, residency, and research. Advertisements for Signature Foot & Ankle.
Our Notice of Privacy Practices provides information about how we may use or disclose protected health information.
The notice contains a patient’s rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent.
The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date.
You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations.
By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive.
By signing this form, I understand that: