New Patient Registration - Total Foot Care Inc of TN

Name(required)

Email(required)

Cell Phone Number

Alternate Phone Number

Date of Birth

Gender

Male Female Intersex/ Nonbinary

Address

Responsible Party

Relationship

Primary Care Physician

Last Visit Date

How did you hear about us?

Google Social Media Friend or Family

Have you seen a podiatrist in the past?

Yes No

If so, when?

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 No

Arthritis

Yes No

Asthma

Yes No

Breastfeeding/ Pregnant

Yes No

Bronchitis

Yes No

Bronchitis

Yes No

Cancer

Yes No

Diabetes

Yes No

Emphysema

Yes No

Gout

Yes No

Heart

Yes No

Hepatitis A/B/C

Yes No

HIV/ AIDS

Yes No

Hypertension (High Blood Pressure)

Yes No

Pneumonia

Yes No

Mitral Valve Prolapse (MVP)

Yes No

Sickle Cell/ Trait

Yes No

Neurological/ Psychological Problems

Yes No

Tuberculosis

Yes No

Are you currently taking any medication?

Yes No

If yes, list medications and dosage

Please indicate if you are allergic to the following.

Aspirin

Yes No

Betadine

Yes No

Codeine

Yes No

Demerol

Yes No

Erythromycin

Yes No

Iodine

Yes No

IVP Dye

Yes No

Latex

Yes No

Morphine

Yes No

Novacain

Yes No

Penicillin

Yes No

Sulfa

Yes No

Tetracycline

Yes No

Xylocaine

Yes No

Other drug allergies

Do you smoke?

Yes No

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

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 No

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 AssignmentI, 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

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

Other Details