mill creek foot & ankle clinic / dr. joseph hall / dr. nathan hansen … · mill creek foot...
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Mill Creek Foot & Ankle Clinic / Dr. Joseph Hall / Dr. Nathan Hansen Phone: (425) 482-6663 FX (425) 482-6665
PATIENT INFORMATION Date: _____________________
Name: _________________________________________________________ SS#:____________________________ Last First middle initial
Address: __________________________________________________City/State/Zip: ___________________________________
Email: __________________________________________________
Home #: ___________________________ Cell #: ________________________ Work #: ______________________________
Gender: M F Age: ________ Birthdate: _________________ Single Married Widowed
Race: American Indian Asian Black Hispanic Pacific Islander Caucasian Other
In case of emergency notify: _____________________ Relationship: ______________Phone: _____________________
Patient Employer: _________________________________Occupation: _______________________________________
Primary Care Physician/Clinic: ________________________________________________________________________
City: ________________ State: ___________ Phone: ______________________________________________________
Whom may we thank for referring you to our office: Internet Phonebook Insurance Website Mail/Coupon
Friend Referral (Name):____________________________________________________________________________
Physician Referral (Name/Address/Phone): ____________________________________________________________
to the patients Insurance Company (ies) and their agents for the purpose of obtaining payment for services and determining insurance
benefits or the benefits payable for related services.
____________________________________________________________________ _____________________
**Signature of Patient, Parent/Guardian or Personal Representative Date
Print name of Patient, Parent or Guardian ____________________________________________________
Acknowledgement of receipt of Notice of Privacy Practices: I acknowledge that I was provided the
Notice of Privacy Practices and that I have read and understand it.
________________________________________________________ _____________________
**Signature of Patient, Parent/Guardian or Personal Representative Date
16708 Bothell Everett Hwy # 204 Mill Creek WA 98012
Insurance Information:
Primary Insurance: __________________________ID #: ______________________ Group #: ______________
Subscriber Name ___________________________________Birthdate: ___________________________
Relation to Patient: ______________________________________Employer: ___________________________________
Secondary Insurance: __________________________ID #: ______________________ Group #: ______________
Subscriber Name: __________________________________Birthdate: ____________________________
Is This An L&I Injury NO ______ YES _____ L&I Claim#: ________________________________________________
Assignment and Release: The above named doctor may use my health care information and may disclose such information
Mill Creek Foot & Ankle Clinic / Dr. Joseph Hall Phone: (425) 482-6663 FX (425) 482-6665
16708 Bothell Everett Hwy # 204 Mill Creek WA 98012 What is the nature of your foot complaint:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Do you smoke: ______ How much: ______ Drink Alcohol: ______How much (circle one): rarely/occasionally/daily
How many servings of caffeine do you consume in a day? _______________
Height: _______ Weight: _______ Shoe Size: ______ Width (circle one) : Narrow/Regular/Wide
Have you had any serious illness or operation? No Yes
If yes, please describe: ______________________________________________________________________
Do you have low back pain? No Yes
Have you tested positive for HIV? No Yes Are you subject to profuse bleeding? ___ No ___ Yes
Please check if you have had any of the following:
Anemia
Asthma
Arthritis
Cramps in feet/legs
Diabetes, Insulin
Diabetes, Orally Controlled
Gout
Heart Problems
Hepatitis
High Blood Pressure
High Cholesterol
Immune Deficiency
Kidney Problems
Liver Problems
Numbness in feet/legs
Swelling in ankles/feet
Thyroid Problems
Tuberculosis
Varicose Veins
Other ___________
Allergies:
No Known Drug Allergies
Adhesive Tape
Contrast Dye
Iodine
Latex
Penicillin
Other Medication:
___________________
Please Note All Current Medications: Name Dosage Frequency
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
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