Pt #
DESERT HILLS PODIATRIC ASSOCIATES
4816 E Camp Lowell Dr, Tucson AZ 85712 (520)881-8640
400 W Camino Casa Verde, Green Valley AZ 85614
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PLEASE PRINT
Patient Last Name ______First Name______Middle Initial____
Mailing Address______
City/State______Zip Code______
Home Phone______Cellular Phone ______Other Phone______
Social Security # (optional)______Birth Date ______Male/Female______
Employer______Phone Number______
May we contact you at work? Y N
Insurance Subscriber if other than patient:
Name______SS #______Date of Birth______
Responsible party (if patient is a minor): Wife Husband Parent Other
Last Name______First Name______
Address______Phone Number______
Who referred you to us? ______Primary care physician ______
Primary Language:______
Medical Information
Please indicate the nature of any problems with your feet or relating leg structure.
______
______
Weight______Height______Shoe Size______
SMOKING STATUS(circle one): Never Smoked,former smoker,smoke every day, smoke some days.
ALLERGIES
□Aspirin□Iodine
□Demerol□Sulfa
□Latex
□Other(please list)
□Codeine□Penicillin ______
□I am not allergic to any medications to my knowledge
Current Medications and dosage, or bring a list
______
Do you have or have you had any of the following:
□Diabetes □Varicose Veins □Leg Cramps
□Anemia □Asthma □Tumors
□Bleeding Problems □Cancer □Gout
□Epilepsy □Glaucoma □High Blood Pressure
□Heart Problems □Kidney Problems □Stomach Ulcers
□Nervousness □Arthritis □Neuro Muscular
□Stroke □Tuberculosis □Other
Are you under the care of a Doctor at this time for any problems? Yes No
Please explain______
______
Have you had any surgical procedures? Yes No
Please explain ______
______
______
Is there anything else we should know about your general health status (e.g. implants or other medical conditions)______
Consent for Services
As a condition of your treatment by this office, all payments are due at the time of service.
Patients who carry medical insurance should understand that all services furnished will be billed to the insurance company. If your insurance company requires referrals, it is the responsibility of the patient to insure there is a valid referral at each visit. If the insurance company does not pay the medical claim or if the service is a non covered benefit, it is the patients’ responsibility to pay for services rendered.
I authorize the release of medical information necessary to process any medical claim. I authorize payment of benefits either to myself, Dr. Robert Chiarello D.P.M. or Dr. Brian Hutcheson D.P.M. as agreed upon at the time of treatment for services rendered.
Signature______Date ______
The following questions can be declined, but we are required to ask.
Race (circle one): Declined, American Indian or Alaska Native, Asian, Black or African American, Native Hawaiian or Pacific Islander, White
Ethnicity (circle one): Declined, Hispanic or Latino, Not Hispanic or Latino
02/2013