Patient Intake Form

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2700 Silverside Rd.
Suite 3B
Wilmington, DE 19810

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Please complete the following form and answer all questions before arriving for your appointment.

Be sure to include your insurance information.
We'll see you soon!

Covid Information

Have you been vaccinated for Covid-19? (*)

Yes No

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Dates of your vaccination and brand name ?

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We're sorry, we are not accepting any unvaccinated patients into our practice at this time.

Patient Information

First name (*)

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Last name (*)

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Your Email Address (Responsible Party) (*)

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Mailing Address (*)

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City (*)

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State (*)

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Zip-Code (*)

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Phone number (*)

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Date of Birth: Month (*)

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Day (*)

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Year (*)

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Sex (*)

Male Female

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Marital Status (*)

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Height (*)

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Weight (*)

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Race(*)

American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Pacific Islander
White
Decline to Specify

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*This information is requested due to Healthcare Reform laws dictated by Congress.

Ethnicity

Hispanic or Latino Non-Hispanic or Non-Latino Decline to Specify Invalid Input

Preferred Language(*)

English Spanish Other

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Specify

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Are you pregnant?(*)

No Yes

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Are you nursing?(*)

No Yes

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Primary Care Physician (*)

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Primary Care Physician Address (*)

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Physician Phone Number (*)

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Date last seen: Month

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Day

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Year

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Pharmacy (*)

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Pharmacy Phone (*)

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Whom may we thank for referring you? (*)

Google / Internet
Friend / Family
Doctor Referral
Insurance Website
Facebook
Other

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Who?

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Other

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Primary Reason for Visit (*)

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Duration of Condition (*)

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What helps / makes it worse?

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Is it limiting your activity level? (*)

Yes No

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Secondary problem (if there is one)

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Please list any drug allergies (*)

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List Medications You Take (*)

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Medical History (please check all that apply) (*)

None of the these
Alzheimers
Anemia
Anxiety
Arthritis
Asthma
Back pain
Bleeding disorders
Cancer
Chest Pain
Chronic skin infections
Clotting disorders
Congestive heart failure
COPD
Crohn's disease
Diabetes (insulin dependent)
Diabetes (non-insulin dependent)
Emphysema
Epilepsy
Eye condition
Fibromyalgia
Gout

Headaches
Hearing disorder
Heart Attack
Heart disease
Hepatitis
Hepatitis B
Hepatitis C
High Blood Pressure
History of DVT/blood clotting
HIV
Hypertension
Irritable bowel syndrome
Keloid/thick scar
Kidney disease
Kidney failure
Liver disease
Lung disease
Lyme’s disease
Multiple Sclerosis
Neuropathy
Osteoporosis
Pacemaker

Palpitations/Arrhythmia
Parkinson's disease
Phlebitis
Poor circulation
Prostate cancer
Prostate enlargement
Pyschiatric disorder
Recurrent kidney infections
Recurrent urinary tract infection
Reflux/heartburn
Rheumatic fever
Sciatica
Seizure disorder
Shortness of breath
Stomach ulcer
Stroke/TIA
Thyroid problem
Tuberculosis
Ulcerative colitis
Vascular disease
Weight gain
Other

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Specify other

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If you have cancer, please list type and treatment

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Please list past surgeries and year surgery was performed (*)

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Is your problem related to a Workman’s Comp injury or an auto/other accident?(*)

No Yes

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We’re sorry we do not treat problems related to Workmen’s comp or accident cases. Unfortunately, you will have to seek care elsewhere.

Social History

Do you drink alcohol?(*)

Never Past Yes

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How often?

Daily 1-2 x Week 1-2 x Month 1-2 x Year Invalid Input

Do you smoke, vape or use chewing tobacco?(*)

Never Past Yes

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Please specify

Cigarettes Cigars Chewing Tobacco Vaping Invalid Input

How many per day?

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Method of Quitting

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Do you have/have had a substance abuse problem?(*)

Never Past Yes

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Please specify

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Family History

Which family members had the below medical conditions? (father, mother, sibling, etc.)

Diabetes

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Stroke

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Cancer

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Arthritis

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Heart Attack

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High Blood Pressure

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Insurance Information

Patient's Relation to the Policy Holder (*)

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HMO (*)

Yes No

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Primary Insurance (*)

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Policy Number (*)

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Policy Holder Name (*)

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Policy Holder Date of Birth: Month (*)

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Day (*)

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Year (*)

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Secondary Insurance

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Secondary Policy Number

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Emergency Contact

First Name (*)

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Last Name (*)

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Relationship to Patient (*)

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Phone (*)

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Responsible Party (if minor patient)

First Name

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Last Name

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Relationship to Patient

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Date of Birth: Month

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Day

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Year

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View Privacy Policy

Consent for Treatment and Acknowledgement of Policies

For any insurance plan that requires authorization from a primary care physician (e.g. HMO, PPO, etc.) it is your responsibility (as patient or guardian) to be sure that this office receives all necessary referrals or authorizations PRIOR to treatment. Professional services are rendered and billed directly to your insurance carrier; however you, the patient/guardian, are directly responsible for services rendered by the doctor. A health insurance policy is a contract between you (the patient or subscriber) and your insurance carrier. You MUST notify this Office of any changes to your insurance policy including policy termination, changes in co-payments or a new insurance policy. If for any reason the insurance carrier denies charges, payments for any services rendered will become the responsibility of the patient/guardian.

I Agree (*)

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All office visit charges and co-pays are due at the time services are rendered. It is the patient who is responsible for any and all financial aspects of services rendered. There will be a charge for returned checks, missed appointments without 24 hours notice and completion of any forms. I agree to pay for all deductibles, co-pays, non-covered services and any portion of covered services not paid in full by my insurance plan and understand that such payments are due at the time of service or immediately upon presentation of the bill. I hereby name Total Foot Care, P.A. (TFC) as my assignee. I instruct my health care benefits plan administrator, i.e. PLAN to pay TFC directly for all professional and medical services provided by TFC through the means of electronic funds transfer(s} (EFT) or by check(s) made payable to and mailed to TFC. I AUTHORIZE THE RELEASE OF ANY MEDICAL INFORMATION NECESSARY TO PROCESS CLAIMS.

I Agree (*)

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The above information is correct to the best of my knowledge. I understand that throughout my treatment, I am responsible for notifying the physician and/or medical staff of any and all updates to the information listed above. I also give permission for photographs of my feet to be taken that are to be kept as part of my medical record only. They will not be published as part of medical research or disbursed in any way without my permission.

I Agree (*)

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I acknowledge that I was provided a copy of the Notice of Privacy Practices for Total Foot Care, PA and I have read (or had the opportunity to read if I so choose) and understood the Notice.

I Agree (*)

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PAYMENT RESPONSIBILITIES

We are pleased to welcome you to our office. New Patients are always appreciated. Our practice has grown as a result of its excellent relationship with our referring doctors and patients. As our patient, please feel free, at any time, to express any concerns or to ask any questions that you may have for the doctor or our staff. In order to assist you in making payment(s) for your podiatric treatment, the following options are listed. Please read them carefully and feel free to discuss them with us.

If you DO NOT have insurance: Payment is due, in full, at the time treatment is provided.

*For your convenience, we accept all major credit/debit cards and cash. We accept personal checks for payments under $50.00.

If you have Insurance: The percentage of coverage by your insurance company may be based on your insurance company’s own reduced fee schedule for medical services and may be less than actual charges resulting in lower coverage for you. Total Foot Care has no control over this situation. Lower payment is a direct result of the plan selected by you or your employer. Please be advised that we cannot waive co-payment. We are required by law to collect co-payment.

Commercial Insurance: We will submit your claim to your insurance carrier for you. You are responsible for any deductible or co-payment not covered by your insurance. Once our office has received payment from the insurance company, you will be billed, with 30 day terms, for any amount still owed. You may choose to keep a credit card on file for those balances left to you by your insurance company.

Medicare: This office accepts Medicare assignment. Medicare patients are fully responsible, however, for the initial yearly deductible and the 20% co-insurance. Federal law requires that physicians collect this amount. If you have a secondary insurance to cover the 20%, we will submit the balance to that insurance for payment and you will only be responsible for the yearly deductible.

Please sign with your initials

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