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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