Medical Registration Form Patient Address: City/Town/Zip: Sex: Age: DOB: Email: Primary Language: Race: Occupation: Employed by: Cutting Edge Foot And Ankle Clinic Home phone: Business phone: Mobile phone: Marital status: Medications: Referring M.D.: Date last seen: Pharmacy: Phone: PCP Name: Telephone Number: Past Medical History: Reason for todays visit: Description of Symptons: BILLING INFORMATION Medical Insurance: ID #: RESPONSIBLE PARTY FOR MINOR CHILD Parent's Name: Address: Phone: Party to be billed: Address: Claim/File #: Date of Accident: EXTENDED AUTHORIZATIONS I hereby authorize Cutting Edge Foot and Ankle Clinic to furnish information to insurance carriers concerning my illness and treatments and I hereby assign to Cutting Edge Foot and Ankle Clinic all payments for medical services rendered to myself or my dependents. I am aware that it is my obligation to know my insurance company's policies and that I am responsible for payment if I have not fulfilled their requirements. I also acknowledge the receipt of HIPPA privacy policy. Signature: Date: CONSENT FOR TREATMENT I hereby request and voluntarily consent to such office care, including routine diagnostic procedures and medical treatment as may be deemed necessary by Cutting Edge Foot and Ankle Clinic and/or his designees. Signature: Date:
