Chart # _________
Queen City Foot & Ankle Specialists
Name: First_________________________________Middle__________________ Last_____________________
Date of Birth ____/____/____ Age: _____ Sex: Male Female Social Security # ______-_____-_________
Email ___________________________ Marital Status: Married / Single / Divorced /Widow
Home Phone # ________________________Work Phone # _____________________Cell Phone # _________________
Nearest Relative to Notify in an Emergency Name:__________________________Phone:________________________
Name of Pharmacy or Drug Store: ___________________________ Phone #___________________
Family Physician:________________________________ Phone #:__________________________________
Physician(s) Currently treating you:__________________________________ Phone#___________________
May we contact your physician(s) about your health? Yes No
Are you under treatment at this time? Yes No Date of Last Visit: ____/____/_____
Are you pregnant or Breastfeeding? Yes No
Current Height _______ Current Weight _______ Shoe Size _______
How did you learn of our office? (please provide names)
__Friend___________________________ __ Doctor______________________________________
__Yellow Pages __Newspaper_______________ __Other: ____________________________
Please describe in great detail the problem you are having with your feet, the duration, and what makes it
I acknowledge that I was provided and opportunity to read the NOTICE OF PRIVACY PRACTICES located on the
clipboard and I understand the Notice.
Signature: _________________________________________________________ Date:______________________
This is important for our records and your health
Are you Allergic or Sensitive to:
Tape or Adhesives? _________________________________________________
Have you had any problems taking aspirin or ibuprofen (Advil, Motrin, Aleve)? Yes No
Mother: __Living __Deceased Cause of Death:_______________
Father: __Living __Deceased Cause of Death:_______________
Brother: __Living __Deceased Cause of Death:_______________
Sister: __Living __Deceased Cause of Death:_______________
Is there a family(blood relative) History of:
__Arthritis __Heart Disease __Diabetes __Stroke __Nerve problems __Mental disease
__Circulation problems __Bunions __Flatfeet __Hammertoes __ Sickle Cell Anemia
Please List all the drugs and herbal supplements that you currently take.
Do you have Diabetes? _____ If yes, Number of years ______
Controlled with: Insulin? _______ Pills?_____________ Diet?_______
Have you ever been treated for any of the following? Please check below.
__Stroke __Heart Problems __Circulation problems __Mental Disease/Depression
__Arthritis __Liver Problems __High Blood pressure __High Cholesterol
__Anemia __Thyroid Disease __Kidney/Bladder Disease __Seizures
__Gout __Asthma __Back pain or injury __HIV (+)
__Cancer (Type?)_______ __Stomach Problems __Bleeding tendencies __Blood Clots
Have you had any previous surgery? Yes No
If yes, please list the surgeries and the approximate date: __________________________Date_______________
Do you drink alcohol or beer? Yes No
__Light usage, 1-2/week __Moderate, 1-2/day __Heavy, more than 2 daily
Do you Smoke? Yes No Number of packs/day?____
Previously smoked? Yes No Number of years________
Employment: __sit at job __stand at job __stand and walk at job __retired
Queen City Foot and Ankle Specialists
If the office does not participate with or accept assignment from your health insurance, payment in full
will be due at the time of service unless prior arrangements have been made.
Office visit co-payments for our participating HMO/PPO insurances are due at the time of service. If we
have to generate a billing statement to collect your co-pay there will be a minimum fee of $5.00 added
for the administrative costs of billing.
If we are a participating provider with your primary health insurance, we are happy to file a claim on
your behalf. However, once the insurance company is billed we allow 60 days for the balance to be paid
by your insurance company. If they do not remit payment within 60 days, the balance will be due in full
from you. If any payment is made by your insurance carrier after your payment has been received we
will gladly refund the overpayment to you within 30 days, providing you do not have any outstanding
accounts with our office.
HMO/PPO claim denials due to no referral of authorization are the responsibility of the patient. Our
office staff will assist you in referral/ pre-certification procedures, but final responsibility lies with the
We encourage our patients to be familiar with their insurance plan.
Please present your insurance card each visit, otherwise your insurance may not cover your visit and you
will be responsible for payment.
There is a $20.00 charge for returned checks in addition to a $5.00 billing fee
All unpaid balances are subject to a 2% interest or minimum $5.00 service charge after 90 days.
Please be on time for your appointment. We respect your schedule, and expect the same in return. If you
need to reschedule your appointment, we require a minimum of 24 hours notice. If you miss a scheduled
appointment without notifying our office a $25.00 charge will be added to your account.
If your account must be forwarded to a collection service and or attorney because of non-payment, you
will be responsible for all collection fees charged by these services.
By my signature I acknowledge receipt of this policy and hereby agree to its terms.
Printed Patient Name: _______________________________ Date: _________________
Authorized Representative: ___________________________ Relation: ______________
Signature of Responsible Party: _____________________________________________