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: