Intake Form

Please complete all required fields!

Please complete the following form and answer all questions before arriving for your appointment.

Be sure to include your insurance information.
We'll see you soon!

Patient Information

First name (*)

Invalid Input

Middle Initial

Invalid Input

Last name (*)

Invalid Input

Your Email Address (Responsible Party) (*)

Invalid Input

Mailing Address (*)

Invalid Input

City (*)

Invalid Input

State (*)

Invalid Input

Zip-Code (*)

Invalid Input

Phone number (*)

Invalid Input

Date of Birth: Month (*)

Invalid Input

Day (*)

Invalid Input

Year (*)

Invalid Input

Sex (*)

Male Female

Invalid Input

Marital Status (*)

Invalid Input

Height (*)

Invalid Input

Weight (*)

Invalid Input

Shoe size (*)

Invalid Input

Race(*)

*This information is requested due to Healthcare Reform laws dictated by Congress.

Ethnicity

Hispanic or Latino Non-Hispanic or Non-Latino Decline to Specify Invalid Input

Preferred Language(*)

English Spanish Other

Invalid Input

Specify

Invalid Input

Are you pregnant?(*)

No Yes Invalid Input

Are you nursing?(*)

No Yes Invalid Input

Have you completed an Advance Directive (living will)? (*)

Yes No

Invalid Input

Primary Care Physician (*)

Invalid Input

Primary Care Physician Address (*)

Invalid Input

Physician Phone Number (*)

Invalid Input

Date last seen: Month

Invalid Input

Day

Invalid Input

Year

Invalid Input

Pharmacy (*)

Invalid Input

Pharmacy Phone (*)

Invalid Input

Who?

Invalid Input

Who?

Invalid Input

Other

Invalid Input

Primary Reason for Visit (*)

Invalid Input

Duration of Condition (*)

Invalid Input

What helps / makes it worse?

Invalid Input

Is it limiting your activity level? (*)

Yes No

Invalid Input

Secondary problem (if there is one)

Invalid Input

Please list any drug allergies (*)

Invalid Input

List Medications You Take (*)

Invalid Input

Specify other

Invalid Input

If you have cancer, please list type and treatment

Invalid Input

Please list past surgeries and year surgery was performed (*)

Invalid Input

Is your problem related to a Workman’s Comp injury or an auto/other accident?(*)

Yes No

Invalid Input

Do you drink alcohol?(*)

Never Past Yes

Invalid Input

How often?

Daily 1-2 x Week 1-2 x Month 1-2 x Year Invalid Input

Do you smoke, vape or use chewing tobacco?(*)

Never Past Yes

Invalid Input

Please specify

Cigarettes Cigars Chewing Tobacco Vaping Invalid Input

How many per day?

Invalid Input

Method of Quitting

Invalid Input

Do you have/have had a substance abuse problem?(*)

Never Past Yes

Invalid Input

Please specify

Invalid Input

Family History

Which family members had the below medical conditions? (father, mother, sibling, etc.)

Diabetes

Invalid Input

Stroke

Invalid Input

Cancer

Invalid Input

Arthritis

Invalid Input

Heart Attack

Invalid Input

Hypertension/High Blood Pressure

Invalid Input

Insurance Information

Primary Insurance (*)

Invalid Input

Primary Insurance Member ID (*)

Invalid Input

HMO (*)

Yes No

Invalid Input

Primary Policy Holder Name (If Primary Policy Holder Is The Patient, Type 'Self') (*)

Invalid Input

Policy Holder Name (*)

Invalid Input

Policy Holder Date of Birth: Month (If Primary Policy Holder Is The Patient, Type Patient's Date Of Birth) (*)

Invalid Input

Day (*)

Invalid Input

Year (*)

Invalid Input

Patient's Relation to the Subscriber (If Primary Policy Holder Is The Patient, Type 'Self') (*)

Invalid Input

Secondary Insurance

Invalid Input

Secondary Member ID

Invalid Input

Occupation (*)

Invalid Input

Employer (*)

Invalid Input

Employer Address

Invalid Input

City

Invalid Input

State

Invalid Input

Zip-Code

Invalid Input

Employer Phone Number

Invalid Input

Emergency Contact

First Name (*)

Invalid Input

Last Name (*)

Invalid Input

Relationship to Patient (*)

Invalid Input

Phone (*)

Invalid Input

Responsible Party (if minor patient)

First Name

Invalid Input

Last Name

Invalid Input

Relationship to Patient

Invalid Input

Date of Birth: Month

Invalid Input

Day

Invalid Input

Year

Invalid Input

View Privacy Policy

All office visit charges and co-pays are due at the time services are rendered. It is the patient who is responsible for any and all financial aspects of services rendered. There will be a charge for returned checks, missed appointments without 24 hours notice and completion of any forms. I agree to pay for all deductibles, co-pays, non-covered services and any portion of covered services not paid in full by my insurance plan and understand that such payments are due at the time of service or immediately upon presentation of the bill. I hereby name AVID Foot & Ankle Center (AFAC) as my assignee. I instruct my health care benefits plan administrator, i.e. PLAN to pay AFAC directly for all professional and medical services provided by AFAC through the means of electronic funds transfer(s) (EFT) or by check(s) made payable to and mailed to AFAC. I AUTHORIZE THE RELEASE OF ANY MEDICAL INFORMATION NECESSARY TO PROCESS CLAIMS.

I Agree (*)

Invalid Input

The above information 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. I also give permission for photographs of my feet to be taken that are to be kept as part of my medical record only. They will not be published as part of medical research or disbursed in any way without my permission.

I Agree (*)

Invalid Input

I acknowledge that I was provided a copy of the Notice of Privacy Practices for AVID Foot & Ankle Center and I have read (or had the opportunity to read if I so choose) and understood the Notice.

Financial Policy

Your insurance policy is a contract that exists between you and your insurance company. Our relationship is with you, the patient, and not the insurance company. If you have questions about your policy, please call the phone number provided on the back of your insurance card. The patient or responsible party is responsible for their bill being paid in full. Please inform us at every visit of any changes to your insurance coverage.

COPAYMENTS: It is a requirement of your insurance company that we collect your co-pay. Payment is required before meeting with the doctor.

I Agree (*)

Invalid Input

DEDUCTIBLES & CO-INSURANCE: If you have a high deductible plan, we may collect a $125 deposit to apply towards your deductible and co-insurance. Any remaining balance after submission to your insurance company is your responsibility.

I Agree (*)

Invalid Input

SELF-PAY (for non-covered products and services and for patients without insurance coverage): Full payment is due at time of service. A down-payment will be required before seeing the doctor. At a minimum, an evaluation and management fee will be charged. Additional procedures/services may be recommended by the doctor. You will be informed of these charges before proceeding with treatment.

I Agree (*)

Invalid Input

REFERRAL: If your insurance plan requires a referral from your primary care doctor, this will be required at the time of your visit. Without a referral available, we may need to reschedule your appointment.

I Agree (*)

Invalid Input

NO SHOW (failure to present for your appointment): 24 hours-notice is required for cancellation of your appointment and failure to do so will incur a $50 fee. Failure to provide 24 hours-notice for a scheduled office procedure will incur a $100 fee.

I Agree (*)

Invalid Input

SURGERY CANCELLATION: Failure to provide 5 business-days notice before surgery will incur a $500 fee.

I Agree (*)

Invalid Input

BALANCES/COLLECTION FEES: If payment of an outstanding balance is not received within 30 days from the postmark date of a mailed statement or e-statement time stamp, a $10 re-billing fee may be added to each additional statement. Our patient portal offers the ability to view statements and submit payments conveniently and securely. Patients with balances more than 90 days overdue will be turned over to collections and a $35 administrative fee will be applied.

I Agree (*)

Invalid Input

FMLA/DISABILITY/MEDICAL RECORDS: There is a $25 charge for having the doctor complete these forms. Requested forms will be completed within 72 hours of diagnosis and care plan. There is a $15 fee to obtain a copy of your medical records.

I Agree (*)

Invalid Input

I have read and understand these financial policies.

I Agree (*)

Invalid Input

PAYMENT RESPONSIBILITIES

We are pleased to welcome you to our office. New Patients are always appreciated. Our practice has grown as a result of its excellent relationship with our referring doctors and patients. As our patient, please feel free, at any time, to express any concerns or to ask any questions that you may have for the doctor or our staff. In order to assist you in making payment(s) for your podiatric treatment, the following options are listed. Please read them carefully and feel free to discuss them with us.

If you DO NOT have insurance: Payment is due, in full, at the time treatment is provided.

*For your convenience, we accept all major credit/debit cards and cash. We accept personal checks for payments under $50.00.

If you have Insurance: The percentage of coverage by your insurance company may be based on your insurance company’s own reduced fee schedule for medical services and may be less than actual charges resulting in lower coverage for you. AVID Foot & Ankle Center has no control over this situation. Lower payment is a direct result of the plan selected by you or your employer. Please be advised that we cannot waive co-payment. We are required by law to collect co-payment.

Commercial Insurance: We will submit your claim to your insurance carrier for you. You are responsible for any deductible or co-payment not covered by your insurance. Once our office has received payment from the insurance company, you will be billed, with 30 day terms, for any amount still owed. You may choose to keep a credit card on file for those balances left to you by your insurance company.

Medicare: This office accepts Medicare assignment. Medicare patients are fully responsible, however, for the initial yearly deductible and the 20% co-insurance. Federal law requires that physicians collect this amount. If you have a secondary insurance to cover the 20%, we will submit the balance to that insurance for payment and you will only be responsible for the yearly deductible.

Please Upload Picture of Your Driver's License

Invalid Input! Pictures must be in png, jpg, or jpeg format!

Please Upload Picture of Your Insurance Card (Front)

Invalid Input! Pictures must be in png, jpg, or jpeg format!

Please Upload Picture of Your Insurance Card (Back)

Invalid Input! Pictures must be in png, jpg, or jpeg format!

Please sign with your initials (*)

Invalid Input

Please ensure you have completed all mandatory fields on this form (indicated with an (*) asterisk next to the field) and please wait until our thank you page loads to ensure the form was successfully submitted otherwise your data will be lost.

Intake Form

Patient Information

Social History

Family History

Insurance Information

Emergency Contact

Responsible Party (if minor patient)

Consent for Treatment and Acknowledgement of Policies

Financial Policy

PAYMENT RESPONSIBILITIES

Connect With Us