New Patient Registration - Total Foot Care Inc of TN

Complete the information below prior to your appointment.

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Thank you for your response. ✨

Name

Cell Phone Number

Alternate Phone Number

Date of Birth (YYYY-MM-DD)

Gender

Male

Female

Intersex/ Nonbinary

Address

Responsible Party

Relationship

Primary Care Physician

Last Visit Date (YYYY-MM-DD)

How did you hear about us?

Google Social Media Friend or Family

Have you seen a podiatrist in the past?

Yes

If so, when? (YYYY-MM-DD)

Name of podiatrist

Podiatrist Location

Preferred Pharmacy

Pharmacy Phone Number

Insurance #1

Insured Name

Insurance #2

Insured Name

Emergency Contact

Relationship

Contact Number

Chief Complaint

Duration

Previous Treatment

Have you had or do you have any of the following conditions?

Anemia

Yes

Arthritis

Yes

Asthma

Yes

Breastfeeding/ Pregnant

Yes

Bronchitis

Yes

Bronchitis

Yes

Cancer

Yes

Diabetes

Yes

Emphysema

Yes

Gout

Yes

Heart

Yes

Hepatitis A/B/C

Yes

HIV/ AIDS

Yes

Hypertension (High Blood Pressure)

Yes

Pneumonia

Yes

Mitral Valve Prolapse (MVP)

Yes

Sickle Cell/ Trait

Yes

Neurological/ Psychological Problems

Yes

Tuberculosis

Yes

Are you currently taking any medication?

Yes

If yes, list medications and dosage

Please indicate if you are allergic to the following.

Aspirin

Yes

Betadine

Yes

Codeine

Yes

Demerol

Yes

Erythromycin

Yes

Iodine

Yes

IVP Dye

Yes

Latex

Yes

Morphine

Yes

Novacain

Yes

Penicillin

Yes

Sulfa

Yes

Tetracycline

Yes

Xylocaine

Yes

Other drug allergies

Do you smoke?

Yes

By checking this box, I agree that I have read and understand this Notice of Privacy Practices

Agree

Patient Name

Parent or Authorized Representative

Signature

Date (YYYY-MM-DD)

Total Foot Care Inc. of Tennessee has my permission to contact me to provide appointment reminders or information about treatment or other health- related benefits or services. I consent to have messages left for me on an answering machine if I am not available.

Yes

Total Foot Care Inc of Tennessee has my permission to discuss information about my health status and treatment, including prescriptions with the following individuals (please provide the name and relationship to the patient)

Name

Relationship to Patient

Name

Relationship to Patient

Name

Relationship to Patient

Total Foot Care Inc of Tennessee has my permission to discuss billing matters with the following individuals (please provide the name and relationship to the patient)

Name

Relationship to Patient

Name

Relationship to Patient

Name

Relationship to Patient

I, the undersigned, give consent to Dr. Tyrone T Davis of Total Foot Care Inc. of Tennessee to examine, diagnose and treat my foot/ ankle condition.
Release and Assignment
I, the undersigned, authorize release of any information necessary to process my insurance claims and assign and request payment directly to Total Foot Care Inc. of Tennessee. I authorize the use of my signature on all insurance submissions. I understand that I am FINANCIALLY RESPONSIBLE for all charges, whether or not paid by insurance. Unpaid balances will be assessed a FINANCE CHARGE, COLLECTIONS FEES, and ATTORNEY FEES if applicable.

Signature

Date (YYYY-MM-DD)

I, the undersigned understand that there is a fee of $50 if I miss three (3) consecutive appointments without providing a 24 hour notice of cancellation to the office. I understand that this fee must be paid in cash, by the patient, prior to any services rendered. I also understand that this fee cannot be billed to my insurance company. I will no longer be allowed to schedule any future appointments; however, I may be seen as a work-in patient.

Signature

Date (YYYY-MM-DD)

Other Details