Preferred Name (required)

Social Security Number (required)

Your Email Address (Responsible Party)(required)

Mailing Address (required)

Primary Care Physician(required)

Primary Care Physician Address(required)

Who referred you to our office?(required)

Google / InternetFriend / FamilyDoctor ReferralInsurance WebsiteFacebookOther

Your Foot Condition (please check all that apply)(required)

Ingrown ToenailsHammer ToesNerve PainAthletes FootTendonitisBlistersHeel FissuresCracked HeelsBunion PainFungal NailsCallus (Hard Skin)Highly Arched FeetHeel PainFlat FeetOther

Primary Reason for Visit(required)

Duration of Condition (required)

What helps / makes it worse(required)

Is it limiting your activity level? (required)

YesNo

Secondary problem (if there is one)

Please list any drug allergies(required)

List Medications You Take (required)

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

None of the theseAlzheimersAnemiaAnxietyArthritisAsthmaBack/neck painBleeding disordersCancerChest PainChronic skin infectionsClotting disordersCongestive heart failureCOPDCrohn's diseaseDiabetes 1Diabetes 2 (insulin dependent)Diabetes 2 (non-insulin dependent)EmphysemaEpilepsyEye conditionFibromyalgiaGoutHeadachesHearing disorderHeart AttackHeart diseaseHepatitisHepatitis BHepatitis CHigh Blood PressureHistory of DVT/blood clottingHIVHypertensionIrritable bowel syndromeKeloid/thick scarKidney diseaseKidney failureLiver diseaseLung diseaseLyme’s diseaseMultiple SclerosisNeuropathyOsteoporosisPacemakerPalpitations/ArrhythmiaParkinson's diseasePhlebitisPoor circulationProstate cancerProstate enlargementPsychiatric disorderRecurrent kidney infectionsRecurrent urinary tract infectionReflux/heartburnRheumatic feverSciaticaSeizure disorderShortness of breathStomach ulcerStroke/TIAThyroid problemTuberculosisUlcerative colitisVascular diseaseWeight loss/gainOther

What was your most recent glucose and hemoglobin A1c?

If you have cancer, please list type and treatment

Please list past surgeries and year surgery was performed

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

YesNo

Do you drink alcohol? (required)

Neverpastyes

How often?

Daily1-2 x Week1-2 x Month1-2 x Year

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

Neverpastyes

Please Specify smoke

CigarettesCigarsChewing TobaccoVaping

How many per day?

Method of Quitting

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

NeverPastYes

Please specify abuse problem?

Primary Insurance(required)

Primary Insurance Address

Secondary Insurance

Secondary Insurance Address

Secondary Policy Number

Employer Address

Employer Phone

Relationship to Patient(required)

Phone(required)

Occupation (required)

Name

Relationship

Date of Birth

Name

Relationship

Date of Birth

For any insurance plan that requires authorization from a primary care physician (e.g. 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.(required)

I agree

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 Sheldon D. Simon, DPM (SDSDPM) as my assignee. I instruct my health care benefits plan administrator, i.e. PLAN to pay SDSDPM directly for all professional and medical services provided by SDSDPM through the means of electronic funds transfer(s) (EFT) or by check(s) made payable to and mailed to SDSDPM. I AUTHORIZE THE RELEASE OF ANY MEDICAL INFORMATION NECESSARY TO PROCESS CLAIMS. (required)

I agree

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.(required)

I agree

I acknowledge that I was provided a copy of the Notice of Privacy Practices for Sheldon D. Simon, DPM and I have read (or had the opportunity to read if I so choose) and understood the Notice.(required)

I agree

Please sign with your initials(required)