New Patient Paperwork

Patient Information

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What's Bringing You In?

Name *

Date of Birth *

Phone *0 / 12

Email Address

Social Security

Gender

Marital Status

Street Address

City

Zip Code

Primary Insurance Name *

Primary Insurance I.D. Number

Secondary Insurance Name

Secondary Insurance I.D. Number

For Medicare Members Only: Please Enter Medicare Number Presented on Card

For Workman's Comp Patients Only: Please Provide Claim Number

For VA Patients Only: Please Provide Authorization Number

Primary Care Physician

Phone

Pharmacy

Location

Emergency Contact

Phone

Relation to Patient

Smoking StatusSmokingNon-SmokerEx-SmokerVapeSmokeless TobaccoRecreational Drugs

If Using Tobacco / How Often?

Occupation

Are You Pregnant?

Any Implanted Devices?

Problems With Anesthesia?

Are You Taking Insulin?

Family HistoryDiabetesArthritisStrokeCancerFoot ProblemsHeart AttackHigh Blood PressureBirth Defects

Surgical History

Medical History: Please Select All That ApplyCornsCallusesIngrown NailsBunionsLower Back PainHammer / Mallet ToeLeg / Foot UlcersBroken Foot / AnkleArch PainWarts

Foot NumbnessToe WalkingFungal NailIn-ToeingLeg / Foot CrampingHigh Arch FeetHeel PainAthlete’s FootNeuromaFlat FeetAlzheimer’s

Ankle SprainFlat FeetKnee PainGoutRashDiabetesStrokeHeart AttackPoor CirculationHigh Blood PressureHeart Condition

Vascular DiseaseAnemiaPhlebitisGlaucomaKidney DiseaseKeloidThyroid Problems

OsteoporosisSciaticaLyme DiseaseRheumatic FeverArthritis / RAHearing / Ear DisorderCancer

EpilepsyNerve DisorderPsychiatric DisorderAsthmaLung DiseaseHepatitisTuberculosis

Allergies

Medications

If Patient is a Minor / Please Provide The Name of a Parent or Guardian

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2021 freeport road, Arnold, PA, 15068 / 724-337-4433