Patient Info Form

Name*

First Last

Date of Birth*

Email*

Enter Email Confirm Email

Driver's License #

Vocational Category

Marital Status

Home Phone

Work Phone

Cell Phone

Home Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Employer or School Name

Responsible Party Info

Name of Responsible Party

First Last

Responsible Party Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Responsible Party Phone

Emergency Contact Info

Emergency Contact Name

First Last

Emergency Contact Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Relationship to Patient

Physician Info

Referring Physician

First Last

Phone

Primary Physician

First Last

Phone

Physical Therapist

First Last

Phone

Who referred you?

First Last

In most instances, we will bill your insurance for payment of our services. However, we do request payment for certain orthotic devices at the time of delivery. We will provide you with the necessary paperwork to file with your insurance company. Your coverage is a contract between you and your insurance carrier. You are responsible for your entire balance in circumstances where your insurance company denies coverage, as well as any remaining balance after insurance has paid. If this matter is turned over for collection, you will be responsible for all collection fees and attorney/court costs incurred. Your signature below indicates your understanding and agreement to accept responsibility for any and all charges incurred through this office and to allow us to release any private health information to file claims with your insurance carrier. I acknowledge that I have received or had access to Medicare Supplier Standard, HIPAA Privacy Laws, and Patient Rights and Responsibilities.

Signature of Responsible Party*

Date

Physician Diabetic Prescription Form

Step 1 of 3

Responsible Party Info

Emergency Contact Info

Physician Info

Primary Insurance Information

Secondary Insurance Information

Patient Medical History

Past Surgeries

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Physician Diabetic Prescription Form

Step 1 of 3

Responsible Party Info

Emergency Contact Info

Physician Info

Primary Insurance Information

Secondary Insurance Information

Patient Medical History

Past Surgeries

Repeater

Repeater

Repeater

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