Foot & Ankle Specialty Clinic William W. Martin, DPM
First Name_______________________ Last Name______________________ Middle______ Date of Birth______________
Age_____
Gender M F
Nickname___________ SSN_________________
Marital Status S D M W Race_______________ Ethnicity______________
Preferred Language_______________ Address___________________________________ City______________
State________ Zip Code___________
Home Phone___________________ Work Phone_______________ Cell_____________________ Primary Doctor_____________________ _______ Preferred Pharmacy_____________________ City______________ Phone Number_____________________ Height____ Weight_____ Shoe Size_____ Emergency contact, relationship, and phone number (not living with you)___________________________________________________________________ MEDICAL HISTORY Circle any of the following conditions you have had in the past: Abdominal Pain Anemia Anxiety Arthritis Asthma Back Problems Bleeding
Blood in stool Breast Cancer Bruising Cancer _____________ Cardiac problems______ Chest pain Cholesterol (High) COPD
Current Review of of Systems Systems (ROS) CONSTITUTION Chills Fatigue Fever Weakness Weight gain Weight Loss HEAD Dizziness Fainting
Cough Dementia Depression Dermatitis Diabetes Type I or II Dizziness Dry Skin Dry Mouth
Edema Fainting GERD Glaucoma Gout HIV Headache Heart attack
Hypertension Hypotension Joint Pain Lesion/Sores Macular Degeneration Memory Loss Migraine Neck pain
Numbness Pneumonia Raynauds Renal Stone (Kidney) Seizure Shortness of breath Sores in mouth Stiffness
Stroke TB Thyroid Ulcer _________ _________ _________
Circle any of the following conditions you currently currently have:
RESPIRATORY Shortness of breath CARDIO Chest pain CHF High Blood Pressure GASTRO Abdominal Pain Stomach issues Diarrhea
MUSC/SKEL Arthritis Joint Pain Gout Back pain Charcot Foot* Cramping Stiffness Paralysis Fracture
Weakness Limb length Discrepancy SKIN Eczema Dermatitis* Nail Change (Thickness, discolored) Itchy Skin (Red, scaly skin)
NEURO Burning Unsteady gait Restless leg* Neuropathy* Parkinson’s
HEMATOLOGIC Blood clots Easily bruise GENITOURINARY Kidney Issues Pregnancy
ENDOCRINE Weakness Weight Changes
If you are a diabetic, please answer the following questions Who is the doctor that monitors your diabetes?___________________________ diabetes?_ __________________________ What was the date of your last visit?_______________ What was your A1C______________ What was your last blood sugar______________ sugar________________ __ Do you currently wear diabetic shoes?_______ shoes?______ _ When was the last time you received a pair of shoes?______________________________ FAMILY HISTORY
Condition Cancer Diabetes Heart Trouble Arthritis Stroke High Blood Pressure Other
FATHER
MOTHER
SIBLING (IF MOTHER OR FATHER HX IS NOT AVAILABLE
SOCIAL HISTORY
Have you ever smoked Y N Do you drink alcohol Y N Medication/Dose/Amount Medication/Dose/Amount
Length of time__________ How often________________ Allergies
Quit Date_____________ Surgical History/Date
FINANCIAL INFORMATION
PRIMARY INSURANCE:
SECONDARY INSURANCE:
ID NUMBER:
ID NUMBER:
NAME
NAME
SUBSCRIBER DOB
SUBSCRIBER DOB
LIFETIME TREATMENT CONSENT AND FINANCIAL POLICY AGREEMENT
This is an agreement between the patient/and or responsible party with Dr. William W. Martin, DPM. By signing this agreement, the patient or responsible party consents to treatment of my foot and/or ankle co ndition. I understand my physician will use his best skill and judgment to accomplish the desired result, but that my physical condition does not warrant or guarantee such result. Also, that my physician forecast of the length of time involved with my condition and the usual and average response in cases similar to mine, but that is not a promise, since my results and response may be different than usual. On my part, I promise full cooperation with my physician whether by surgical or non- surgical means, I understand that if I do not follow my physician’s instructions, concerning my care and treatment, including any necessary physical therapy the outcome of my care and treatment could be put in jeopardy and an unfavorable result may occur. I hereby give permission to my physician to photograph, administer treatment, and perform such procedures as may be necessary in the diagnosis and/or treatment of my foot and/or ankle condition. Prescription medication policy is as follows: 1. 2. 3.
If you are in need of pain medication, you must be seen in clinic by Dr. William W. Martin. No exceptions will be made. Please plan ahead if you are going to be unable to be seen in clinic. Any other medication refill request must be made through your pharmacy for you. They will send us the appropriate information. Prescription refills can take 24-48 hours to process, so plan accordingly
I am aware that, as a courtesy, Dr. William W. Martin’s office will bill my insurance for services rendered. As the patient o r guardian, I understand that it is my responsibility to provide accurate insurance information to the Foot & Ankle Specialty Clinic. I understand that I am responsible for following the claims until they get paid. Any balance left owing after 60 days will be subject to an annual percentage rate of 12%. As a courtesy to patients who would like to be set up on a monthly payment plan, we can accommodate this with completion of proper paperwork. I am aware that there will be a $10 a month account maintenance fee added to my balance each month this carries over. I understand that I am responsible for the account balance remaining on this account and agree to pay any balance remaining. All charges on statements are considered correct unless a dispute is filed within 30 days of receiving the statement. Not all services, fees, or retail items may be covered by insurance plans, and may be deemed patient or responsible party responsibility. Payment is due at the time of service, upon receipt of statement, or upon date agreed to on payment plan contract. Payments cannot and will not be delayed or excused for any reason, including outcome of medical treatment, liens, lawsuits, coverage determination, or delay of processing claims. If balance remains over 90 days, FASC reserves the right to file account with collections. Should this occur patient/responsible part will be liable for all legal fees and collection costs. Dr. Martin reserves the right to refuse service to anyone who refuses to sign the Lifetime Treatment Consent and Financial Policy Agreement. Should any changes be made to this agreement, we will provide you with a new form for you to review and sign. I have been given the opportunity and have reviewed the privacy policy of the Foot & Ankle Specialty Clinic, the Prescription Agreement, and the Lifetime Consent and Financial Policy Agreement and agree to adhere to these agreements.
Patient/Responsible Party______________________________ _____________
Date______________________________ __________________
