Podiatry Intake Form | Podiatrist, Foot Doctor Pittsburgh, PA 15227 and 15202

Please complete all required fields!

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

All fields with an asterisk (*) must be completed before submitting.

Be sure to include your insurance information.
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Request appointment for (*)

Pittsburgh-South Hills Office Pittsburgh-Bellevue Office

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Patient Information

First name (*)

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Middle Initial

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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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Age (*)

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Preferred Phone

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Alternate Phone Number Type

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Alternate Phone Number

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Marital Status (*)

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Sex (*)

Male Female

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Spouse's Name

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Spouse's Date of Birth

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If we need to contact you, are we permitted to leave a message on your voicemail?

Yes No Invalid Input

Height (*)

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Weight (*)

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Shoe size (*)

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Preferred Language (*)

English Spanish Other

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Specify

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Have you completed an Advance Directive (living will)? (*)

Yes No

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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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Diabetic Doctor (if applicable)

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Diabetic Doctor Address

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Diabetic Doctor Phone Number

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Date last seen: Month

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Day

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Year

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List Medications You Take (*)

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Pharmacy (*)

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Pharmacy Phone (*)

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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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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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Do you drink alcohol? (*)

Never Past Yes

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How Much Do You Drink?

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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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Hypertension/High Blood Pressure

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Anesthesia Reaction

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Bleeding Disorder

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Family History Unknown

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Other

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Are you pregnant?

Yes No Invalid Input

Are you Breastfeeding?

Yes No Invalid Input

Chance of Pregnancy?

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Insurance Information

Subscriber's Name (*)

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Subscriber's D.O.B. (*)

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Patient's Relation to the Subscriber (*)

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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 (owner of policy) (*)

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Policy Holder (owner of policy) Date of Birth: Month (*)

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Day (*)

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Year (*)

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Group Number (*)

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Insurance Phone Number (*)

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Insurance Address (*)

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Insurance City (*)

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Insurance State (*)

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Insurance ZIP-Code (*)

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Secondary Insurance

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Secondary Policy Group Number

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Secondary Policy Number

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Occupation (*)

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Patient's Employer (*)

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Patient's Employer Address

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City

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State

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Zip-Code

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Patient's Employer Phone 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

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 Associates in Podiatry (AIP) as my assignee. I instruct my health care benefits plan administrator, i.e. PLAN to pay AIP directly for all professional and medical services provided by AIP through the means of electronic funds transfer(s) (EFT) or by check(s) made payable to and mailed to AIP. 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, and I consent to such diagnostic procedures and medical care as deemed necessary by the doctor for my treatment. 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 Associates in Podiatry and I have read (or had the opportunity to read if I so choose) and understood the Notice.

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, checks and cash.

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. Associates in Podiatry 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.

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 full name (*)

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Disclosure of Health Information: I wish to allow disclosure of my health information to the following family members, friends or individuals. I understand that I may change this list at any time by informing this office in writing of the change.

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By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this Intake Form. If you have completed this form with the assistance of the New Patient Coordinator, you agree that she is authorized to complete and sign this form on your behalf.

Please Upload Picture of Your Insurance Card (Front)

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Please Upload Picture of Your Insurance Card (Back)

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Please sign with your full name (*)

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Please ensure you have completed all mandatory fields on this form (indicated with an (*) asterisk next to the field) and please wait until our thank you page loads to ensure the form was successfully submitted otherwise your data will be lost.

Intake Form

Patient Information

Family History

Review of Systems

Insurance Information

Emergency Contact

Responsible Party (if minor patient)

PAYMENT RESPONSIBILITIES

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Intake Form

Patient Information

Social History

Family History

Review of Systems

Insurance Information

Emergency Contact

Responsible Party (if minor patient)

Consent for Treatment and Acknowledgement of Policies

PAYMENT RESPONSIBILITIES

Connect With Us