Patient Registration Form

  • PATIENT REGISTRATION FORM

  • Date of Birth*
     / /
  • Gender*
  • Marital Status*

  • Appointment confirmations are via text and email unless the OPT-OUT form is completed.

  • Format: (000) 000-0000.
  • Type*
  • Format: (000) 000-0000.
  • Type
  • Primary Language*
  • Ethnicity*
  • Race*
  • Who can we thank for referring you to our practice?

  • Family / PCP Physician:

  • Format: (000) 000-0000.
  • DATE LAST SEEN
     / /

  • Pharmacy:

  • Format: (000) 000-0000.

  • Emergency Contact:

  • Format: (000) 000-0000.

  • Advance Care Directive

  • An Advance Care Directive is a legal document that provides instructions for medical care and only goes into effect if you cannot communicate your own wishes.

  • Do you have an Advance Care Directive?
  • Format: (000) 000-0000.

  • INSURANCE INFORMATION

    *** Insurance Card(s) and photo ID must be given to front desk at time of service ***

  • Primary Insurance

  • Referral Required?*
  • Date of Birth*
     / /

  • Secondary Insurance

  • Do you have a secondary insurance?*
  • Referral Required?*
  • Date of Birth*
     / /

  • Will this treatment be done because of?

  • Workers Compensation Injury?
  • Date of Injury
     / /
  • Do you have a first report of injury?
  • Format: (000) 000-0000.
  • Auto / Personal Accident?
  • Date of Injury
     / /
  • Format: (000) 000-0000.

  • I, the undersigned, certify that I (or my dependent) have provided Complete Foot & Ankle Specialists, LLC with all my correct insurance information and certify coverage with my insurance as presented and assign directly to Complete Foot and Ankle Specialists, LLC all insurance benefits, payable to me for services rendered. I understand that I am responsible for payment of deductibles, co-payments, and/or non - covered services and other fees AT THE TIME OF SERVICE. I understand that it is my responsibility to inform Complete Foot and Ankle Specialist, LLC if there is a change in my health insurance information.

    I understand all appointment confirmations are via text and email. I further understand I may be contacted at my preferred phone number, via text, email, patient portal and/or mail regarding appointment, medical, and billing information. If I would like to change these communication settings, I understand I need to complete an OPT-OUT form.

  • Date*
     / /
  • Should be Empty: