Patient Forms

Patient Intake Form

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Sex:
May we leave a message?
May we leave a message?
Marital Status:
Send treatment updates?
Is there a family member or other person that you would like for us to share your medical information?

Insurance Information

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Do you have Advanced Directives or a Living Will?
Are you up to date with the Flu Shot?
Are you up to date with the Pneumonia Vaccine (if older than 65)?

Please list all medications you are currently taking (including over the counter meds and herbal supplements):

Medication
Dosage
How often do you take?

Please list all prior surgeries:

Type of Surgery
Date
Type of Surgery
Date

Social History

Use of alcohol:
Use of Tobacco:
Use of Tobacco:
How much are you on your feet at work:

Family History

Do you have a family history of?:

Conditions:

Diabetes
Cancer
Heart Disease
High Blood Pressure
Stroke
Coronary artery disease
Thyroid Disorder
Rheumatoid arthritis
Other

Your Medical History

Do you have any allergies to the following?

Please list all medications you are allergic to:

Medication
Reaction

Have you ever had any of the following?

Acid Reflux
Fibromyalgia
Neuropathy
Anemia
Gout
Open Sores
Arthritis
Heart Attack
Pneumonia
Asthma
Heart Disease
Polio
Back Trouble
Hepatitis
Rheumatic Fever
Bladder Problems
HIV+/AIDS
Sickle Cell Disease
Abnormal Bleeding
High Blood Pressure
Skin Disorder
Blood Clots
Kidney Disease
Sleep Apnea
Blood Transfusions
Liver Disease
Stomach Ulcers
Bronchitis
Low Blood Pressure
Stroke
Cancer
Migraine Headache
Thyroid Disease
Diabetes T1 T2
Mitral Valve Prolapse
Tuberculosis

Where is the pain/problem located? Mark on the pictures below:

Download Image
Max. file size: 512 MB.

Current Problem

Did you pain or problem begin:
How would you describe your pain?
How would you rate your pain on a scale from 1 to 10?
Since the time your pain or problem began, has it:
What makes your pain or problem feel worse?
Policy
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Patient Financial Policy Form

Thank you for choosing our practice for your Podiatric needs. We are committed to providing you with the best possible medical care. Please understand payment of your bill is considered a part of your treatment. The following is a statement of our Financial Policy, which we require you to read and sign prior to any treatment.

  • Full payment is expected on the day medical services are provided unless you have health insurance coverage with a plan that we have a written agreement. You are responsible to pay your:
    • DEDUCTIBLE (an amount you must pay first out of pocket each year before your insurance will pay for any service)
    • COPAY (an amount you must pay before each visit to a doctor)
    • CO-INSURANCE (an amount which is usually a percentage of the fee that your insurance company will not pay).
  • I understand that I am financially responsible for any balance not paid by my insurance company.
  • I understand that it is my responsibility to provide the office with current insurance information and notify the office if there have been any changes.
  • All patients are responsible for any non-covered services and will be asked to sign an Advanced Beneficiary Notice (ABN) for any non-covered services or supplies prior to the service. You will be responsible for your deductible, co-pays, and any service deemed medically unnecessary and all non-covered services or supplies.
  • A $30 return check fee will be assessed to your account for every check returned to this practice. No checks will be redeposited. We accept cash, credit card, Apple Pay, and check.
  • Some plans require prior authorization or referral from your primary care provider in order for our physicians to see you and receive payment from your insurance plan. You are responsible for obtaining this referral PRIOR to your visit. Without a referral, you will need to reschedule your appointment or pay the full payment for the medical services rendered.
  • In order to best serve all of our patients needing appointments, please respect our 24-hour cancellation window prior to your appointment. This allows us to schedule a patient that needs to be seen and avoids a $25 no-show fee on your account.
  • Self Pay Patients: I understand that I am responsible for the payment of my bill, in full, at the time of service.
  • Diabetic Patients: In order to comply with federal guidelines, I understand that I am responsible to bring with me a copy of my last A1c/lab results AND the date last seen by the physician managing my diabetes in order for my insurance to be billed for at-risk diabetic foot care. I understand that if I do not have required information (A1C and date of visit), my visit may be denied and I will be responsible for the bill.
  • I understand there is a $20 fee to complete disability paperwork associated with my care. I will be provided with a standard form free of charge; however, if additional disability forms (such as FMLA) require completion, I understand that the $20 fee is required.
  • I have read the above policy and understand it fully.

PLEASE READ THE ABOVE INFORMATION CAREFULLY BEFORE SIGNING. By signing below, I acknowledge that I have read, understand, and agree to the terms of this policy. I also request that payment of authorized benefits be made to Dr. Mark Ross DPM PC d/b/a Taylor Made Podiatry. I authorize them to release medical information to my insurance plan and its agents any information needed to determine these benefits or the benefits payable to related services. The undersigned certifies that they are either the patient or is duly authorized by the patient's general agent to execute the above and accept the terms.

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