DOB:

Sex□ Male □ Female S M D W

Retired? □ Y □ N Spouse's Name

Spouse's Phone

□ Y □ N Email Address

□ Asian □ White/Caucasian

□ Black/African American □ Other

□ Hispanic/Latino

Preferred Language □ Native American/Alaska Native

□ Native Hawaiian/Other Pacific Islander

PRIMARY PHYSICIAN

PHARMACY NAME

PRIMARY INSURANCE:

SECONDARY INSURANCE:

SIGNATURE DATE

RELATIONSHIP (if other than patient) REASON (if unable to sign)

I hereby authorize the release of any medical information pertaining to my treatment or information necessary for processing insurance claims and

payment of the medical benefits to myself or the party who accepts assignments. This authorization will remain valid until revoked by me in writing. I

understand that I am legally responsible for all charges whether or not reimbursed by my insurance company. I understand and accept that if I fail to pay

my bill or any monies due and owing Palm Beach Foot and Ankle by the scheduled due date, and fail to make acceptable payment arrangements to bring

my account current, PBFA may refer my delinquent account to a collection agency. I further understand that if PBFA refers my account balance to a third

party for collection, a collection fee will be assessed and will be due in full at the time of the referral to the third party. The collection fee will be

calculated at the maximum amount permitted by applicable law but not to exceed 30% of the amount outstanding. For purposes of this provision, the

third party may be a debt collection company or an attorney. If a lawsuit is filed to recover an outstanding balance, I shall be also responsible for any

costs associated with the lawsuit such as court costs or other applicable costs. Finally, I understand that my delinquent account may be reported to one

or more of the national credit bureaus.

SIG

NA

TUR

E

Group Number Date of Birth

Policy Holder (if other than patient)

Policy Number Relationship to Patient

Group Number Date of Birth

Fax Number

Address

Phone Number

Fax Number

INSU

RA

NC

E IN

FOR

MA

TIO

N

Palm Beach Foot and Ankle participates with Medicare and many other insurance networks. It is ultimately the patient's responsibility to ensure network

participation with the insurance company. PBFA cannot assume responsibility for network participation. Please provide a photo ID and insurance cards

to receptionist.

Policy Holder (if other than patient)

Policy Number Relationship to Patient

Do you have a living will?

Emergency Contact (other than spouse)/Relationship:

Phone #

PC

P/P

HA

RM

AC

Y Address

Phone Number

Date Last Seen

City/State/Zip Code Marital Status

Employer

Occupation

Palm Beach Foot and Ankle - Patient RegistrationP

ERSO

NA

L IN

FO

PATIENT NAME Appt Date/Time

Local Mailing Address SSN:

City/State/Zip Code Home Phone #

Alternate Address Cell Phone #

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

□

□

□

□

Patient Signature Date

MEDICARE SIGNATURE ON FILE

Patient Name (please print) Medicare Number

Patient Signature Date

WHOM MAY WE THANK FOR SENDING YOU TO OUR OFFICE?□ □

□ □

□ □

□ □

WORKER'S COMPENSATION / ACCIDENT INFORMATIONIs your treatment today due to a work related injury? □ Yes □ No

What is the date of your injury?

Do you have written authorization from your employer and comp carrier to be treated? □ Yes □ No

Is your treatment today a result of a motor vehicle accident? □ Yes □ No

What is the date of your injury?

Is your treatment today a result of an accident / liability case? □ Yes □ No

What is the date of your injury?

Patient Signature Date

Newspaper Insurance Provider List

Other Passed by Location

Other:

Authorization Expiration Date:

I request that payment of authorized Medicare benefits be made either to me or on my behalf of Palm Beach Foot and

Ankle for any services furnished me by the listed provider/supplier. I authorize any holder of medical information about

me to release to the Health Care Financing Administration and its agents any information needed to determine these

benefits or benefits payable to related services. I understand that my signature requests that payment be made and

authorizes release of medical information necessary to pay the claim. If "other health insurance" is indicated in item 9 of

the HCFA-1500 form, or elsewhere on other approved claim forms or electronically submitted claims, my signature

authorizes releasing of the information to the insurer or agency shown. In Medicare assigned cases, the

provider/supplier agrees to accept the charge determination of the Medicare carrier as the full charge, and the patient is

responsible only for the deductible, coinsurance, and non-covered services. Coinsurance and the deductible are based

upon the charge determination of the Medicare carrier.

Provider: Palm Beach Foot and Ankle

Doctor Verizon Yellow Pages

Patient The Yellow Book

Palm Beach Foot and Ankle

I acknowledge that I was provided a copy of the Notice of Privacy Practices (posted in the reception room) and that I

have read them or declined the opportunity to read them. I understand the Notice of Privacy Practices discloses how we

may use and disclose my medical information.

I understand that this authorization is voluntary and if disclosed, it will expire one year from the date of execution if no

authorization date is given below. I acknowledge and agree that the practice may disclose my protected health

information and information contained in my medical record to the following:

Spouse:

Legal Representative:

Describe the pain/discomfort: □ Burning □ Numbness □ Sharp □ Other

When did the pain/discomfort begin?

What makes the pain/discomfort better?

What makes the pain/discomfort worse?

ALLERGIES: List all drug, food and environmental allergies and describe reaction: □ NONE

□ Penicillin □ Aspirin □ Narcotic Agent/Codeine□ Anesthesia □ Shellfish □ Sulfa Drugs□ Nickel/Metal □ Radiographic Contrast Dye

□ Other

MEDICATION HOW OFTEN MEDICATION HOW OFTEN

PROCEDURE DATE PROCEDURE DATE

FAMILY HISTORY (please check & list relationship)CONDITION SELF FAMILY/Relationship CONDITION SELF FAMILY/RelationshipANEMIA □ □ KIDNEY DISEASE □ □ARTHRITIS □ □ LIVER DISEASE □ □ASTHMA □ □ MENTAL ILLNESS □ □BLEEDING DISORDERS □ □ MITRAL VALVE PROLAPSE □ □CANCER □ □ MULTIPLE SCLEROSIS □ □CIRCULATION PROBLEMS □ □ NAIL DISORDERS □ □DIABETIC (how long?) □ □ NERVE DISORDERS □ □DIABETES AVG GLUCOSE □ □ OBESITY □ □EPILEPSY □ □ PHLEBITIS □ □FOOT PROBLEM(S) □ □ PULMONARY DISEASE □ □GOUT □ □ PNEUMATIC FEVER □ □HEART DISEASE □ □ STD □ □HEPATITIS □ □ SKIN PROBLEMS □ □HIGH BLOOD PRESSURE □ □ STOMACH/INTEST PROBLEMS □ □HIGH CHOLESTEROL □ □ STROKE □ □HIV/AIDS □ □ THYROID DISEASE □ □INJURY/TRAMA MAJOR □ □ VARICOSE VEINS □ □

DO YOU?Drink alcohol? Y N How often?

Smoke tobacco? Y N How often?

Have a history of drug abuse? Y N Explain

Caffeine Use? Y N Explain

DO YOU?Exercise? Y N Height:

Are you pregnant? Y N Weight:

Shoe Size:

Patient Signature Date

SOC

IAL

SOCIAL HISTORY

MIS

C

MISCELLANEOUS

MED

ICA

L H

ISTO

RY

MEDICATION: Please list all medications, herbal supplements, and vitamins.

If Medication list is attached, please check here. □

□ NONE

SURGERY: Please list all major surgery and date performed. □ NONE

FAM

ILY

History & Medical HistoryIt's important that we learn your history!

TOD

AY

'S V

ISIT

EXPLAIN YOUR FOOT/ANKLE PROBLEM □ RIGHT □ LEFT

□ Fever □ Chills □ Sweats □ Weight Change

HEAD / EYES / EARS / NOSE / THROAT

□ Wear Contact Lens □ Nosebleeds □ Neck Pain □ Dizziness

□ Double Vision □ Wear Eyeglasses □ Eyesight Problems □ Sore Throat

□ Difficult Swallowing □ Cataract □ Dentures □ Ringing in Ears

CARDIOVASCULAR

□ Chest Pain / Discomfort □ Cardiovascular Symptoms □ Heart Murmur

□ Swelling Lower Extremity □ Leg Pain with Exercise □ Palpitations

HEMATOLOGIC / LYMPHATIC

□ Bleeding Problem □ Swollen Glands □ Lymphoma

□ Anemia □ Skin Lump / Location

RESPIRATORY

□ Difficulty Breathing □ Wheezing □ Previous Pulmonary Disease

□ Exposure to TB □ Coughing □ Pulmonary Symptoms

GASTROINTESTINAL

□ Nausea □ Vomiting □ Diarrhea

□ Decrease in Appetite □ Abdominal Pain □ Constipation

ENDOCRINE

□ Often Thirsty □ Frequent Urination □ Thyroid Disease

□ Urinary Symptoms □ Prostate Problems □ Prior Kidney Disease

MUSCULOSKELETAL

□ Musculoskeletal Symptoms □ Feeling Weak □ Joint Pain, Arthralgia

□ Weakness of Limbs □ Prior Fracture

NERVOUS SYSTEM

□ Ataxia □ Speech Difficulties □ Headache □ Convulsions

□ Neuropathy □ Confusion / Disorientation □ Fainting

SKIN

□ Rash □ Ulcer □ Lesions □ Sun Sensitivity

□ Color Change □ Slow Healing □ Infections □ Cracking

□ Eczema (Pruritus) □ Growth □ Hair Loss

□ Dermatitis □ Rheumatoid Arthritis □ Lupus □ Collagen Vascular

□ Nervousness □ Tension □ Depression

Patient Signature Date

CONSTITUTIONAL

ALLERGIC / IMMUNOLOGIC HISTORY

PSYCHIATRIC

REVIEW OF SYSTEMS: Please check any of the following that you are currently experiencing or have recently experienced.

WELCOME INFORMATION

We would like to take this opportunity to welcome you to our office. We hope that your visit will be pleasant. If our staff can do anything

to make you feel more comfortable, please don’t hesitate to ask. Please read the following information regarding our office policies and

your financial responsibility. Please understand that your insurance is a contract between YOU and your INSURANCE COMPANY. We

are not a party to that contract. You will be responsible for any deductible and/or copayment at the time of service. Payment for all

services is due at the time that services are rendered unless payment arrangements have been approved in advance by our staff. We

accept cash, checks, MasterCard, Visa, and American Express.

We may accept assignments of insurance benefits in certain circumstances. You will be responsible for balances NOT covered or paid

by your insurance company. If payment is not received within 90 days from the date of service, you will be responsible for the balance

on your account. You will receive separate bills from outside laboratories or Pathologists if any lab work is performed as we do NOT

handle the billing for lab work done outside our office. We will gladly discuss your proposed treatment and answer any questions relating

to your insurance.

CONSENT FOR EVALUATION & TREATMENT

To the Patient: You have the right, as a patient, to be informed about your condition and the recommended surgical, medical, or diagnostic

procedure to be used so that you may make the decision whether or not to undergo any suggested treatment or procedure after knowing

the risks and hazards involved. At this point in your care, no specific treatment plan has been recommended. This consent form is simply

an effort to obtain your permission to perform the evaluation necessary to identify the appropriate treatment and/or any identified

condition(s).

This consent provides us with your permission to perform reasonable and necessary medical examinations, testing and/or treatment. By

signing below, you are indicating that (1) you intend that this consent is continuing in nature even after a specific diagnosis has been

made and treatment recommended; and (2) you consent to treatment at this office or any other satellite office under common ownership.

The consent will remain fully effective until it is revoked in writing. You have the right at any time to discontinue services. You have the

right to discuss the treatment plan with your physician about the purpose, potential risks and benefits of any test ordered for you. If you

have any concerns regarding any test/treatment recommended by your health care provider, we encourage you to ask questions.

I voluntarily request a physician, and/or other health care provider or the designees as deemed necessary, to perform reasonable and

necessary medical examination, testing, and treatment for the condition which has brought me to seek care at this practice. I understand

that if additional testing, invasive or interventional procedures are recommended, I will be asked to read and sign additional consent

forms prior to the test(s) or procedure(s).

I have read and understand the financial policy of this office as it applies to me and will abide by it. I also certify that I have read and fully

understand the above statements and consent fully and voluntarily to its contents.

_________________________________________________________________ ___________________________________

SIGNATURE OF PATIENT OR PATIENT REPRESENTATIVE DATE

_________________________________________________________________ ___________________________________

SIGNATURE OF WITNESS DATE

Palm Beach Foot and Ankle

Dr. Alan Hartstein ● Dr. Hisham Ashry ● Dr. Jonathan Moskovits

Dr. Xavier Sanchez ● Dr. Jeffrey Rockefeller ● Dr. Kali Etheredge ● Dr. Kristin Silinski