NameDOB MM slash DD slash YYYY AddressGenderAddress City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands MobileEmail Preferred PharmacyPhonePrimary Care DoctorPatient HeightPatient WeightShoe sizeHow did you hear about us?Women:Is the problem from an injury? Yes No Currently Pregnant? Yes No If the patient is a Minor, what is the Relationship of person Accompanying to the patient? Father Mother Sibling Grandparent Legal Guardian Other OtherParty responsible for paymentPhoneAddress Street Address City State / Province / Region By signing below, 1. I am acknowledging that I have read or had the opportunity to read, the Notice of Privacy Practices. (Copy available at the desk) 2. I authorize Infinity Foot and Ankle or its staff to disclose my individually identifiable health information to insurance carrier(s) for the purpose of obtaining payment to the doctor for services rendered and allow insurance companies to process the claim. I understand that this authorization is voluntary. SignatureDate MM slash DD slash YYYY NameDOB MM slash DD slash YYYY Allergies: None Penicillin Sulfa Iodine Latex Other Type of Allergic Reaction: Rash Itching Blisters Swelling Other Surgeries you’ve had: None Tonsillectomy Hysterectomy Appendectomy Bypass Angioplasty Other surgeries OtherOtherOther surgeriesComplications from surgeryTypeTypeAmount per dayAmount per dayNumber of Years of UseNumber of Years of UseTobacco Use Never Past Use Current Use Alcohol Use Never Past Use Current Use Recreational Drug Use Never Past Use Current Use TypeTypeTypeTypeCircle any symptoms you are havingGeneral Fever Chills Eyes Change in Vision Blurred Vision Double Vision Cardiovascular Leg Pain While Sleeping Leg Swelling Leg Pain While Walking Respiratory Cough SOB Musculoskeletal: Bone/Joint Pain Sore Muscles Weakness Neurologic Numbness Tingling Burning Sensation Dizziness Poor Balance Endocrine Thirsty Urinating Frequently Integument Rash Itching Wounds NameDOB MM slash DD slash YYYY Personal Medical History ADHD Alcoholism Anemia Anxiety Arthritis Asthma Arrhythmia Bipolar Bladder Problems Bleeding Problems Cancer Congestive Heart Failure Crohn’s Disease COPD/Emphysema Other Personal Medical History Dementia Depression Diabetes Diverticulitis DVT GERD(Reflux) Glaucoma Gout Headache Heart Attack Hiatal Hernia High Blood Pressure Kidney Stones Kidney Disease High Cholesterol HIV Personal Medical History Hepatitis Irritable Bowel Syndrome Lupus Liver Disease Macular Degeneration Neuropathy Osteopenia/Osteoporosis Parkinson’s Disease Peripheral Vascular Disease Pulmonary Embolism Rheumatoid Arthritis Seizure Disorder Sleep Apnea Stroke Thyroid Disorder Ulcerative Colitis OtherCancerWhat brings you into our office today?Is the problem from an injury? Yes No Rate your pain 0 1 2 3 4 5 6 7 8 9 10 Location (Right/Left)(Foot/Toe/leg) of problem/pain?Describe type of pain Burning Throbbing Aching Stabbing Tingling How long have you had this problem?How did the problem start? Slowly over time Rapidly How has the problem been over time? Worsened Stayed the same Improved Have you seen anyone else with this problem? Yes No Have you had any treatment for the problem? Yes No Have you had this problem before? Yes No What seems to make the problem worse?What seems to make the problem better?NameDate MM slash DD slash YYYY Medication ListMedication NameIf you are currently NOT taking any medication, please initialOffice use OnlyFinancial Policy We will collect your deductible, copay, coinsurance and any uncovered services or the percent you are responsible for at the time of visit. Please be prepared to pay at the time of check in before you are seen by the doctor. We do not bill for deductibles. It is the patient’s responsibility to know the terms of their insurance plans. We obtain our information from your insurance company's provider portal. We will file your claim with your insurance company as a provider for your plan. If your insurance denies payment for services rendered it becomes patient responsibility. Should your account become delinquent over 90 days it is transferred to a collection agency. Fees may apply. Self Pay Patients : This category includes patients with no insurance and the patients who have an insurance plan with which we do not participate. Payment for medical services is required at time of visit. We accept cash, check and all credit cards, debit cards with a service fee of $2.00. If you have any questions regarding this financial policy, please ask or call before you are seen by the doctor. Patient or Guardian SignatureDate MM slash DD slash YYYY Print NameCommunication ConsentNameDOB MM slash DD slash YYYY I consent to receive communications from Infinity Foot and Ankle byUntitled Automated reminder Voice messages Home Phone NumberUntitled Automated reminder Text messages Cell Phone NumberUntitled Automated reminder Email messages Email AddressSignatureDate MM slash DD slash YYYY Cancellation Policy Infinity Foot and Ankle is committed to providing all of our patients with the very best care. In order to do that we must manage our schedule to both maximize flow and maintain adequate patient volume. Late cancellations (less than 48 hours in advance of appointment) and no-shows hamper our ability to do that. Please, if you are unable to make your appointment, call us at 678-639-4209 48 hours prior to your scheduled appointment to notify us of any changes or cancellations. To cancel a Monday appointment, please call our office by Friday before 10am. If appointments are not canceled by at least 48 hours prior to your scheduled appointment, a late cancellation fee will be charged in the amount of $75. Thank you in advance for your understanding. Printed NameDate MM slash DD slash YYYY Signature Δ
