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PATIENT DEMOGRAPHIC INFORMATION FORM

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PATIENT
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Gender (Please circle)
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EMERGENCY CONTACT
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OTHER
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GUARANTOR IF OTHER THAN PATIENT

Please Note· Anyone under the aee of 18 must be accompanied by a parent or legal guardian.

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IF PRIMARY INSURANCE HOLDER IS NOT THE PATIENT
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PLEASE REVIEW THE FOLLOWING; SIGN AND DATE BELOW:

understand that I am responsible for any and all charges that my insurance deems to be patient responsibility. I understand that I am responsible for any and all charges that are denied by insurance. I authorize the release of information for insurance purposes concerning treatment of the above named patient. I authorize payment of any insurance benefits for medical or surgical service to Paradise Valley Foot & Ankle, PLLC. I authorize use of my signature for all insurance submissions. I am aware that there is a charge for missed appointments and late cancellations. 

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MEDICAL HISTORY FORM

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Are you currently or have you ever been treated for:

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Do you have allergies to medications?
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If so, please provide:

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Prescription medications you currently take: 

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Over the counter medications you currently take:

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Do you exercise?
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Do you smoke?
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Do you drink?
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Recreational drug use?
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Surgical History

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Do you have joint implants?
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Have you had ANY trauma to your lower extremities
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Do you experience:

Difficulty with healing
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Scarring
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Leg cramping
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Low back pain
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Swelling in feet or legs
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Numbness in feet or legs
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Have you had any prior treatment for the above problem?
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