Full name as written on health insurance card*
Phone number*
Email*
Birth Date*
Health insurance information* Insurance ID number:
Insurance Eligibility contact number (on the back of the card):
Insurance Information:
Authorization/Referral Number if HMO:
Nature of your foot and/or ankle problem* Please specify which foot you have a problem with. Right FootLeft Foot
If multiple problems, please list them all which as much detail as possible
Please describe the pain (aching, stabbing, throbbing, sharp, dull, etc.):
Onset of issue: Did the pain come on suddenly (possibly due to an injury) or gradually?
How long have you been experiencing the pain?
Have you been treated for this problem? If yes, which treatments were given.
Was the treatment by another physician? Which specialty? (For example, podiatrist, my primary care doctor, etc)
Were any X-Rays or MRI’s done? If so which facility?
Have you self-treated? How?
Do you work? If so, on your feet? Do you sit most of the time?
Do you do a lot of housework? Yardwork? If so, how many hours per day? Per week?
Have any questions about treatment? Feel free to make an appointment, Our team will reach you soon!
