Intake Form

Call Us

South Scottsdale Office: (602) 955-3338
Mesa Office: (480) 833-5966
North Scottsdale Office: (480) 483-9000
Sun City Office: (623) 977-8388

Request Appointment

Call Us

South Scottsdale Office: (602) 955-3338
Mesa Office: (480) 833-5966
North Scottsdale Office: (480) 483-9000
Sun City Office: (623) 977-8388

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

Be sure to include your insurance information.
We'll see you soon!

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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Sex (*)

Male Female

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Marital Status (*)

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Height (*)

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Weight (*)

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Shoe size (*)

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Race(*)

*This information is requested due to Healthcare Reform laws dictated by Congress.

Ethnicity

Hispanic or Latino Non-Hispanic or Non-Latino Decline to Specify

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Preferred Language(*)

English Spanish Other

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Specify

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Are you pregnant?(*)

No Yes

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Are you nursing?(*)

No Yes

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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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Pharmacy (*)

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Pharmacy Phone (*)

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Pharmacy Cross Streets

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Who referred you to our office? (*)

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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Secondary problem (if there is one)

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Please list any drug allergies (*)

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List Medications You Take (*)

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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 often?

Daily 1-2 x Week 1-2 x Month 1-2 x Year

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Do you smoke, vape or use chewing tobacco?(*)

Never Past Yes

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Please specify

Cigarettes Cigars Chewing Tobacco Vaping

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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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Insurance Information

Subscriber's Name (*)

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Patient's Relation to the Subscriber (*)

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Subscriber's Date of Birth: Month (*)

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Day (*)

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Year (*)

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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 (*)

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Policy Holder Date of Birth: Month (*)

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Day (*)

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Year (*)

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Secondary Insurance

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Secondary Policy Number

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Occupation (*)

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Employer (*)

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Employer Address

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City

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State

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Zip-Code

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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

Who may receive information regarding your Protected Health Information? Check all that apply

Spouse
Children
Parent/Guardian
Significant Other/Friend

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Name (Spouse)

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Name (Children)

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Name (Parent)

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Name (Other/Friend)

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Date Of Birth (Spouse) Month:

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Date Of Birth (Children): Month

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Date Of Birth (Parent) : Month

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Date Of Birth (Other/Friend): Month

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Day

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Day

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Day

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Day

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Year

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Year

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Year

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Year

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May we leave messages regarding test results and appointments on your answering machine?

Yes No

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Assignment and Release
I certify that I, and or my dependent(s) have insurance coverage and assign all benefits directly to the office of Arcadia Foot and Ankle. I understand I will be responsible for any portion of the claim, which is denied or not covered by my insurance company. I authorize the release to my insurance carriers any information necessary to process this claim.

ACKNOWLEDGEMENT OF REVIEW OF NOTICE OF PRIVACY PRACTICES:
I have received a copy of the Privacy Policy from this provider and authorized the above list of persons who may receive my Protected Health Information. I may revoke this at any time by giving written notification to this provider. Arcadia Foot and Ankle participates in an organized health care arrangement consisting of the greater Phoenix metropolitan area hospitals as well as physicians who have medical staff privileges at one or more of these hospitals. Participants in this arrangement work together to improve the quality and efficiency of the delivery of health care to their patients. As a participant in this arrangement, we may share your PHI with other members of this arrangement for purposes of treatment, payment or health care operations of this organized health care arrangement.

Signature of Responsible Party (type your name) (*)

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Patient Financial Responsibility

I HEREBY AUTHORIZE MY INSURANCE COMPANY TO MAKE PAYMENTS DIRECTLY TO: Arcadia Foot and Ankle

I understand that I am financially responsible for any co-payments, deductibles, co-insurance, and all charges, which are not covered by my insurance. I understand that there will be a $25.00 service charge on all returned checks. I understand that verification of benefits is not a guarantee of payment. (Insurance benefits are determined by your insurance company when the claim is received.) I understand that I will be responsible for any portion of the claim that is allowed by, but not covered by, my insurance company.

I Agree (*)

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Delinquent accounts will be turned over to a collection agency without notice. Accounts will be considered delinquent if unpaid after 60 days. In the event my account is turned over for collection, I will pay all reasonable collection, court and attorney costs at the time the account is considered delinquent.

Signature of Responsible Party (type your name) (*)

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APPOINTMENT NO SHOW POLICY: I understand that I am responsible for any missed appointments without 24 hour notification and will be responsible for a charge of $75.00.

Signature of Responsible Party (type your name) (*)

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RELEASE AND REQUEST OF INFORMATION:
I hereby authorize Arcadia Foot & Ankle to release or request any medical information or incidental information by my referring physician or any other physician who have been or may become involved in my care.

Signature of Responsible Party (type your name) (*)

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Our physicians are bilingual in English, Spanish, and Portuguese

Patient Information

Social History

Family History

Insurance Information

Emergency Contact

Responsible Party (if minor patient)

Patient Financial Responsibility

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