COLORADO PODIATRY CONSULTANTS, PC Michael Zyzda, DPM Scott Taylor, DPM

2460 West 26th Ave. Suite 180C, Denver, CO 80211

410 S Wilcox, Castle Rock, CO 80104 30940 Stagecoach Blvd., Evergreen, Co.80439 26659 Pleasant Park Rd, Conifer, CO 80433 1930 S Federal Blvd #A, Denver, CO 80219

Welcome to Colorado Podiatry Consultants! We are Medical and Surgical specialists treating all conditions of the foot and ankle. Our practice has been in existence for over 25 years. The doctors of Colorado Podiatry Consultants have completed years of training along with advanced post residency training (Surgical and Orthopedic Board certification). They have full hospital privileges in many Denver area hospitals and surgery centers. We participate in most major insurance plans. We pride ourselves in our personal touch from attentive, devoted physicians to caring and helpful staff. Check out the medical staff information page on our website, www.cpcdenver.com, for each doctors individual training and background.

Services Common conditions treated by our doctors include: ! Diabetic Foot and Nail Care ! Flat Feet ! Sports Medicine ! Arthritis ! Heel pain and Plantar Fasciitis ! Ingrown and fungal childrens foot

problems

! Complicated wounds and infections (circulation, pressure, bone and diabetic wounds)

! Bunions ! Ingrown and Fungal nail problems ! Hammertoes ! Fractures of the foot and ankle ! Orthotics/Bracing

! Warts (Office CO2 laser) ! Burning feet (Anodyne treatments

available in office)

Products We offer many products including but not limited to: ! Office Shoe Program ! Special Medicare approved

prescription Crocs ! Tea tree oil - used for nail fungus

and athletes foot ! Strasburg socks – used to treat

plantar fasciitis ! Superfeet shoe inserts ! A variety of toe pads ! Crocs Rx ! Athletic tape.

Office Hours: Monday – Friday 8:30am – 5:00pm Phone: 720-855-9214 Fax: 720-855-9291

www.cpcdenver.com

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COLORADO'PODIATRY'CONSULTANTS,'PC'MICHAEL!ZYZDA,!DPM!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!SCOTT!TAYLOR,!DPM!

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�FEMALE!!!!!!�MALE!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!�MARRIED!!!!!!�SINGLE!

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First'Name:________________________''''Mi:___________''Last'Name:___________________________________'

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Nickname:____________________'''Date'of'Birth:______________Social'Security#:_________________________'

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EGmail:________________________________________________________________________________________'

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Home'phone:__________________'Cell:________________________'Work:_______________________________'

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ADDRESS:_________________________________'''''''City:______________''''State:________'''Zip'Code:________'

Preferred!method!of!communication:!!!!!!!Text:______!!!!!!!EEmail:______!!!!!!!!!Home!phone:______!!!!!!Cell:!_______!

Party!responsible!for!payment:!!!Name:___________________________!Relationship!to!patient:!_______________!

Adddress:_______________________________!!Phone#:____________________!EEmail:_____________________!

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PRIMARY'INSURANCE:_____________________________'''''''''''Member'ID#:______________________________'

Secondary'Insurance'Information:!________________________!!!Member'ID#:_____________________________'

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Emergency'Contact'Info:''''''First'Name:_______________________'''Last'Name:____________________________'

Relationship:______________''Address:__________________________________Phone#:____________________'

*PRIMARY'CARE'PHYSICIAN*________________________'Date'Last'Seen:____/____/____''Telephone#________'

How!did!you!hear!about!us?!Google:____!!Insurance:!____!!Friend:____!Dr.!Referred:_________________________!

Other:_________________________________________________________________________________________!

I hereby authorize Colorado Podiatry Consultants, PC and/or associates to treat the patient identified above. I acknowledge that I am responsible to pay all charges for all treatments administered by the physician and am required to give a 24 hour cancellation notice or a $25.00 fee will be assessed. I understand that insurance may not pay for all charges and that I am obligated to pay for all charges not covered by insurance. I understand that I am responsible for all costs of collection should my account be turned over to a collection agency or attorney, including attorney fees and collection fees in the amount of 30% of the current balance due. I hereby authorize my insurance benefits to be paid directly to the physician and I am financially responsible for non-covered services. I also authorize the physician to release any information necessary in the processing of all insurance claims and/or the collection of my account.

___________________________________________ ____________________ Patient or responsible party signature Date ! ! !

COLORADO PODIATRY CONSULTANTS, PC Specialists of the Foot and Ankle

Michael Zyzda, DPM, FACFS* Scott Taylor, DPM

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Patient'Responsibility:'Our!practice!is!committed!to!providing!the!best!treatment!for!our!patients.!Patients!are!responsible!for!all!charges!resulting!from!treatment!provided!by!their!physician.!As!a!service!to!you,!we!will!bill!most!insurance!carriers!directly.!However,!primary!responsibility!for!the!account!is!yours.!Providing!correct!insurance!billing!information!is!the!responsibility!of!the!patient.!If!your!insurance!changes,!please!present!your!insurance!card!at!your!next!visit.!All!patients!must!complete!our!patient!registration!form!before!seeing!the!doctor.!!! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!______________(Initial) !! ! ! ! !!!!

Payment'Arrangements:'New'and'Established'Patients:'The!portion!that!insurance!will!not!pay!is!due!at!the!time!of!visit.!Insurance!companies!do!not!guarantee!payment.!If!there!is!a!balance!due!after!insurance!pays,!payment!is!due!within!30!days!of!the!first!billing.!Accounts!with!balances!over!90!days!will!be!assessed!a!processing!fee!each!month. ______________(Initial) !! ! ! ! ! !!!!!!!!!'

HMO/PPO!coEpayments!and!deductibles,!if!required!by!your!plan!are!due!at!the!time!of!each!visit.!'

We!accept!VISA,!MASTERCARD,!DISCOVER,!CARE!CREDIT,!CHECKS,!CASH!AND!MONEY!ORDERS.!!

'Referrals:'Many!insurance!carriers!require!a!referral!from!your!Primary!Care!Physician!before!you!receive!care!from!a!specialist;!it!is!your!responsibility!to!obtain!a!referral!or!prior!authorization!if!your!medical!coverage!requires!it.!A!phone!will!be!provided!for!your!call,!please!get!the!name!of!the!person!who!authorizes!your!visit.!! !!!!!!!_____________(Initial) !! ! ! ! ! !

Insurance'Billings:'Please!be!aware!that!some!or!perhaps!all!of!the!services!you!receive!may!be!nonEcovered!services!and!not!considered!reasonable!and!necessary!under!your!insurance!plan.!In!this!instance,!you!will!be!responsible!for!payment.!We!will!submit!the!claim!to!your!insurance!carrier!on!your!behalf!with!necessary!information.!If!we!are!nonEparticipating!with!your!insurance,!you!must!pay!for!services!upfront!and!acknowledge!you!are!being!told!we!are!nonEparticipating!with!your!insurance.!We!will!still!submit!the!claim!for!you!if!need!be.! ! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!______________(Initial) !! ! !!!!!!!!!!

MEDICARE:'Our!physicians!are!participating!providers.!We!bill!Medicare!as!your!primary!insurer!and!we!will!forward!onto!your!secondary.!Please!be!sure!to!give!us!correct!information!concerning!your!primary!and!secondary!insurance.!Also!be!prepared!to!provide!the!name!of!your!Primary!Care!Doctor!and!the!last!date!seen,!this!information!is!required!at!EVERY!appointment.!! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!______________(Initial)

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I'have'read'and'accept'this'Credit'Policy.''

_______________________________________''''''''''''''''''''''''''''''''''''''''''''''''''''''''____________________'

Signature'of'patient'or'guardian' ' ' ' ' ' Date''

COLORADO PODIATRY CONSULTANTS, PC MICHAEL ZYZDA, DPM SCOTT TAYLOR, DPM

Medical History

Name:__________________________________________________ Today’s Date:_________________

Date of Birth:_____________ Age:_________ Sex: Female � Male �

Describe the problems you are having with your foot (feet) and/or ankle(s).

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

On the diagram, please mark the place(s) where you are experiencing pain your feet.

LEFT FOOT RIGHT FOOT

How long has it been painful?______________ When did it begin?___________________ If this was caused by an injury or accident, please indicate if this was work related or the result of a car accident. � Work Accident � Auto Accident Date of Accident______________ What treatment have you received from the other Dr.’s and/or how have you treated the condition at home? ______________________________________________________________________________

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REVIEW OF SYSTEMS Have you had or have any of the following medical problems? Please check all that apply to you.

� Diabetes � Frequent infections � HIV positive (AIDS) � Heart attack or heart trouble � Allergies or hay fever � Gout � Leg or foot circulation problems � Stomach ulcers � Tendonitis � High blood pressure � Bleeding ulcers � Chronic back pain � Heart murmur � Liver or kidney disease � Artificial joint � Mitral valve prolapse � Frequent urinary tract infections � Nerve pain � Stroke � Hepatitis � Skin diseases / rashes � Excessive bleeding � Arthritis � Slow/difficult healing � Leg or lung blood clots � Numbness or weakness � Easily scar � Shortness of breath � Low pain tolerance � High or low thyroid � Transplant patient � Chronic leg sores or foot sores � Asthma (heart,lung,liver,kidney,etc) � Foot or toe amputations � Pacemaker

� Constipation Please give details about the marked conditions. Please also list any medical problems that are not listed.

Page 2 of Medical History Patient’s Name:__________________________________________ DOB:____________ AGE:_____ Are you currently under the care of a physician for any of the previous mentioned conditions? Please print their name and telephone number below. _____________________________________________________________________________________

List all previous surgeries and/or serious illnesses or accidents. _____________________________________________________________________________________

_____________________________________________________________________________________

Are you currently taking any medications? Yes No (Circle answer that applies.)

Please mark below any that apply to you:

� Antibiotics or sulfa medications � Blood thinners � Water pills � Aspirin � Insulin � Tranquilizers/sedatives � Cortisone/steroids � Sleeping pills � Estrogen/hormones � High blood pressure medication � Nitroglycerin � Oral diabetes medication � Heart medication � Thyroid medication � Birth control pills � Arthritis or gout medication Please list the name and dosage of each medication you are currently taking. If you have a list already written, we will make a copy for our records. _____________________________________________________________________________________ _____________________________________________________________________________________ What is the name and telephone number of your pharmacy?_____________________________________ Are you ALLERGIC to or have you had a bad reaction to any medication? Yes No (Circle answer) Please mark below any that apply: � Local anesthetics � penicillin or other antibiotics � sulfa medication � sedatives or sleeping pills � aspirin � iodine � adhesive tape � pain medications. Please list all medication names that you are allergic to. Please include what type of allergic reaction you have (difficulty breathing, upset stomach, hives): __________________________________________________________________________________________________________________________________________________________________________ Family History/Social History: Is there a family (blood relative) history of: (Please mark all that apply) � Heart disease � arthritis � bleeding disorder � neurological disorder � stroke � bunions � hammertoes � flat feet � circulation problem of the feet or legs � diabetes Please list any other conditions that are not listed above: _____________________________________________________________________________________

Please describe your type of employment: _____________________________________________________________________________________

Average activity or amount of time on your feet during the day__________________________________

Do you drink alcohol or beer? Yes � No � Amount of use: Daily � Occasionally � Frequently � Do you smoke?Yes � No � # of packs per day____ Previously smoked? Yes � No � # of years___

Are you /could you be pregnant? Yes � No � Have you ever had a blood transfusion? Yes � No �