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Online New Patient Form

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Marital status is required.
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Name of responsible party is required.
Relationship of Responsible Party is required.
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Year is required.
Social Security Number.
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City of Responsible Party is required.
State of Responsible Party is required.
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Employer of Responsible Party is required.
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City of Work of Responsible Party is required.
State of Work or Responsible Party is required.
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Primary Insurance is required.
Insured is required.
Policy number is required.
Group number is required.
Secondary Insurance is required.
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Emergency contact is required.
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In your employment do you:
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What do you do after work?
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Please select each item as it applies to you.
Nature of Problem
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Allergies
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Please list any medication you take, prescription and over the counter:
Name of Medication         Reason for taking it          How often do you take it
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Please list any previous surgeries or hospitalizations, dates and reasons:
Surgery / Hospitalization         Approximate dates          Reason
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Your height is required.
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Your right shoe size is required.
Your left shoe size is required.
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Quantity is required.
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Women
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Diabetes/Circulation
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Patient Financial Policy
We are dedicated to providing the best possible care and service to you and regard your complete understanding of our financial policies as an essential element of your care and treatment. If you have any questions, please discuss them with our front office staff or supervisor.
  • Patients who carry health insurance should remember that professional services are rendered and charged to the patient and not the insurance companies. Your insurance is a personal contract between you and your insurance company. If you would like us to file your claim for you, please provide your card to the receptionist. Without your card or proof of insurance, your claims can not be filed. Payment is due in full on the date of service unless other arrangements have been made or we have a contract stating otherwise with your insurance company. We accept cash, check, Visa, Master Card, and American Express.
  • All health plans are not the same and do not cover the same services. In the event your health plan determines a service to be "not covered", or you do not have authorization, you will be responsible for the complete charge. We will attempt to verify benefits for some specialized services; however, you remain responsible for charges to any service rendered.
  • Past due accounts are subject to collection proceedings. All fees including, but not limited to collection fees, attorney fees and court fees shall become your responsibility in addition to the balance due this office.
  • There is a service fee of $25.00 for all returned checks. Your insurance company does not cover this fee.
  • There is a service fee of $50.00 for missed appointments. 24 hour notification is required for cancellations.
  • You must inform the office of all insurance changes, authorization, and referral requirements. In the event the office is not informed, you will be responsible for any charges denied.
  • There are certain surgical procedures that require pre-payment. You will be informed in advance if your procedure is one of those. In that event, payment will be due one week prior to the surgery.

I hereby authorize payment directly to Atlantic Foot & Ankle Specialists for the surgical and or medical benefits, if any, otherwise payable to me for services. I understand that I am financially responsible for the charges not covered by my insurance.

I authorize Atlantic Foot & Ankle Specialists to release any information, for insurance purposes, required in the course of my treatment.

I acknowledge that I was provided a copy of the Notice of Privacy Practices and that I have read (or had the opportunity to read) and understood the notice.

Patient Record Of Disclosures
You may leave messages with, discuss my treatment, appointment or other scheduling that may occur or give other information as necessary with the following family, friends or personal representatives. I understand that Atlantic Foot & Ankle Specialist, PC will refuse to discuss my information with anyone NOT listed below, except in a life-threatening emergency. I also understand that this consent does not apply to medical providers.
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