New Patient Form

PCP Physician

Phone

Date Last Seen

Pharmacy Name

Phone

Who is referring you?

Current Medications

No known medications

I take the following medications

Name

Dose

Name

Dose

Name

Dose

Please use this space for additional information regarding your medications and dosages

Allergies

No known allergies

No known drug allergies

Name

Reaction

Name

Reaction

Name

Reaction

Please use this space to add additional information regarding allergies

Vital Signs

Blood Pressure

Height

Weight

Patient Acknowledgement - PLEASE READ AND SIGN

The information on my intake form is correct to the best of my knowledge. I understand that throughout my treatment, I am responsible for notifying the physician and/or medical staff of any and all updates to the information listed above. (Assignment of Benefits): I authorize payment of medical benefits to the practice named above. (Release of Information): I authorize the release of any medical information necessary to process this claim ()

I am aware that all insurance information given to Fit Feet Podiatry is to be true and up to date. If for any reason my insurance information changes I will be responsible to let Fit Feet Podiatry know immediately. If I fail to let Fit Feet Podiatry know, I will be responsible for any unpaid bills.

Please sign/write your name - I have read the above and agree to the terms.

New Patient Form

Address

Medical History

Vital Signs

Please Read Carefully!