Patient Information Form

Patient Information

Last Name

First Name

Middle Initial

Street Address

City

State

Zip

Date of Birth

Age

Social Sec #

Gender

M F

Marital Status

Single Married Divorced Widowed

Home Phone

Cell Phone

Work Phone

Contact Preference

Phone

Postal

Text

Ethnicity

Unspecified Hispanic or Latino Not Hispanic or Latino Unknown

Race

Unspecified White American Indian or Alaska Native Native Hawaiian or other Pacific Islander Black or African American Asian Other Race

Preferred Language

English Spanish Other Unspecified

If other, please specify

Employer Information

Employer

Occupation

Street Address

City

State

Zip

Who to contact in an emergency:

Name

Relation

Phone #

If the patient is a minor, please complete this section

Parent/Guarantor Last Name

First Name

Middle Initial

Street Address

City

State

Zip

Date of Birth

Age

Social Sec #

Home Phone

Cell Phone

Work Phone

How did your hear of our clinic?

Physician Yellow pages Website Radio Insurance Friend

Primary Care Physician

Phone

Referring Physician

Phone

Insurance Information

Primary Insurance Company

Subscriber Name

Date of Birth

Address

City

State

Zip

Policy #

Group #

Employer

Patient’s relationship to the policyholder

Self Spouse Dependent

Secondary Insurance Company

Subscriber Name

Date of Birth

Address

City

State

Zip

Policy #

Group #

Employer

Patient’s relationship to the policyholder

Self Spouse Dependent

All Patients, Please Read & Sign

I authorize payment of medical benefits from Medicare, Medigap, private and/or group insurance be made on my behalf to Idaho
Foot & Ankle for any services or supplied furnished to me. I authorize any holder of medical information about me to release to the
Health Care Financing Administration or my insurance company any information needed to determine benefits for related services.
I also take responsibility for payment of charges, regardless of payment or denial of payment from my insurance company.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature of Patient/Guarantor

Date

Your information will be encrypted.