New Patient Paperwork Patient Information Name(required) Date of Birth(required) Sex Male Female Email(required) Phone #(required) Social Security # Marital Status: Occupation: Smoking Status: What is bringing you into Pioneer Foot Care? Address(required) City/State(required) Zipcode(required) Emergency Contact Phone # Relation Primary Care Physician(required) Phone # Pharmacy Name/Location(required) Primary Insurance Company(required) ID #(required) Group #(required) Secondary Insurance Company ID # Group # Medical History(required) Stroke Heart Attack High Blood Pressure Phlebitis Vascular Disease Heart Condition Anemia Poor Circulation Glaucoma Diabetes Kidney Disease Keloid/ Thick Scar Alzheimer's Osteoporosis Sciatica Lyme Disease Rheumatic Fever Arthritis Hearing Disorder Epilepsy Nerve Disorder Psychiatric Disorder Asthma Lung Disease Tuberculosis Hepatitis Liver Disease Thyroid Problem None of the Above Continued(required) Corn/Calluses Fungal Nails Leg/Foot Ulcers Broken Foot/Bone Hammer/Mallet Toe Arch Pain Lower Back Pain Warts Ingrown Nails Foot Numbness Broken Ankle Leg/Foot Cramp High Arch Feet Heel Pain Toe Walking Athlete's Foot Neuroma Bunions Ankle Sprain Flat Feet Rash Gout Problems None of the Above Family History(required) Diabetes Arthritis Stroke Cancer Foot Problems Heart Attack High Blood Pressure Birth Defects None of the Above Medications(required) Allergies(required) Surgical History If Patient is a minor, please provide name of parent or guardian who is responsible for financial and medical decisions. SUBMIT *Be sure to hit submit before exiting! You can also print this page and bring it with you. Share this:TwitterFacebookLike this:Like Loading...
