New Patient Registration Complete the information below prior to your appointment. Name(required) Email(required) Cell Phone Number Alternate Phone Number Date of Birth Gender Male Female Intersex/ Nonbinary Marital Status Single Married Divorced Legally Separated Widowed 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 How often do you consume alcohol? Daily Weekly Monthly Occasionally Never 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 Send Δ