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Home
Locations
- Arnold
- Charleroi
- Gibsonia
- Greensburg
- Mars
- Wexford
Our Services
Our Doctors
Appointments
- New Patient
- Existing Patients
Contact Us
About Us

New Patient Paperwork

Be Sure to Fill Out All Boxes and Submit!

What is Bringing You In Today?(required)

Full Name(required)

Date of Birth(required)

Gender(required)

SS#(required)

Phone Number(required)

Email(required)

Address(required)

City/State(required)

ZipCode(required)

Insurance Name(required)

Insurance I.D.

Group [If Any]

Secondary Insurance Name

Insurance I.D.

Group [If Any]

Pharmacy(required)

Location(required)

Primary Care Physician(required)

Phone Number(required)

Emergency Contact(required)

Phone Number(required)

Relation(required)

Smoking / Chew / Vape Status(required)

Marital Status(required)

Occupation (required)

Is This Injury Work Related?

Are You Pregnant? [If Applicable]

Family History Diabetes

Arthritis

Stroke

Cancer

Foot Problems

Heart Attack

High Blood Pressure

Birth Defects

Foot History Corn

Calluses

Fungal Nail

Leg / Foot Ulcer

Broken Foot / Ankle

Hammer / Mallet Toe

Arch Pain

Lower Back Pain

In-Toeing

Warts

Ingrown Nails

Foot Numbness

Leg / Foot Cramps

High Arch Feet

Heel Pain

Toe Walking

Athlete's Foot

Neuroma

Bunions

Ankle / Foot Sprain

Flat Feet

Rash

Gout

Medical History Knee Pain

Stroke

Heart Attack

High Blood Pressure

Phlebitis

Vascular Disease

Heart Condition

Anemia

Poor Circulation

Glaucoma

Diabetes

Kidney Disease

Keloid

Alzheimer's

Osteoporosis

Sciatica

Lyme Disease

Rheumatic Fever

Arthritis / RA

Hearing / Ear Disorder

Epilepsy

Nerve Disorder

Psychiatric Disorder

History Continued Asthma

Lung Disease

Tuberculosis

Hepatitis

Liver Disease

Thyroid Problems

Cancer

Please List Any Surgical History

Please List Any Allergies

Please List Any Medications

Any Issues With Anesthesia?

If Yes, What

Any Implanted Devices?

If Yes, What

If Patient is a minor, please provide name of parent or guardian who is responsible for financial and medical decisions.

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Once you submit the New Patient Paperwork, you will receive an email confirming we received your paperwork

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