New Patient Form PODIATRIC REGISTRATION AND HISTORY Step 1 of 2 50% DR. JOSEPH BARAKPATIENT INFORMATIONDate(Required) MM slash DD slash YYYY Patient(Required) Address(Required) City(Required) State(Required) Zip(Required) Sex(Required) Male Female Age:(Required) Birthday:(Required) Marital Status(Required) Single Married Widowed Separated Divorced Phone Number(Required)Email Address(Required) Employer:(Required) Employer Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Work Phone:(Required) Spouse's Information:Name:(Required) Birthday:(Required) SS:(Required) Occupation:(Required) Employer:(Required) Whom may we thank for referring you?(Required) INSURANCEWho is responsible for this account?(Required) Relationship to Patient:(Required) Insurance Co:(Required) Group #(Required) Policy Number(Required) Is patient covered by additional Insurance?(Required) Yes No Subscriber Name:(Required) Birthday:(Required) SS #(Required) Relationship to Patient:(Required) Insurance Co:(Required) Group#(Required) ASSIGNMENT AND RELEASEI the undersigner certify that I for my dependency have insurance coverage with(Required) and assign directly to Dr. Joseph Barak all insurance benefits. If any otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.Responsible Party Signature(Required)Relationship(Required) Date(Required) MEDICARE AUTHORIZATION I request that payment of authorized Medicare benefits be made either to me or on my behalf to Dr. Josph Barak for any services furnished me by that physician. I authorize any holder of medical information about me to release to the Health Care Financing. Administration and its agents any information needed to determine these benefits or the benefits payable for related services. I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. If "Other health insurance" is indicated in item 9 of the HCFA-1500 form. or elsewhere on other approved claim forms or electronically submitted claims. my signature authorized releasing of the information to the insurer or agency shown. In Medicare assigned cases. the physician or supplier agrees to accept the charge determination of the Medicare carrier as the full Charge. and the patient is responsible only for the deductible. co-insurance. and non- covered services. Co-insurance and the deductible are based upon the charge determination of the Medicare carrier. Beneficiary Signature(Required)IN CASE OF EMERGENCY, CONTACTEmail:(Required) Home PH:(Required)Work PH:(Required)ext(Required)Mobile:(Required)CONTACT INFORMATIONName:(Required) Relationship:(Required) Home PH:(Required)Work PH:(Required)Mobile:(Required)MEDICATIONSInclude prescriptions. over-the-counter medications and vitamins:(Required)Pharmacy Name(s)(Required)Pharmacy Phones(s)(Required)Do you take oral contraceptives?(Required) Yes No ALLERGIES(Required) Adhesive Tape Anticoagulant Therapy Aspirin Codeine Demerol Iodine Local Novocaine Penicillin Seafoods Sulfa None Select AllDo you take alcohol? Yes No How many times a week? Other:(Required) DR. JOSEPH BARAKPODIATRIC HISTORYWhat is the chief complaint for which you are to be treated (include foot, ankle, Knee, hip and thigh complaints)?(Required) Have you ever been to a Foot Doctor before?(Required) Yes No Name:(Required) Last Visit:(Required) Is there any personal or family history of diabetes?(Required) Yes No Cigarette Tobacco Use(Required) Years Smoked(Required) Athletic activities in which you participate (please list and indicate frequency)(Required) Please indicate which foot problems you now have or have had in the past:(Required) Ankle Pain Athlete's Foot Bunions Corns & Calluses Cramps or Numbness in Feet or Legs Flat Feet Foot or Leg Cramps Heel Pain Ingrown Toenails Plantar Warts Tired Feet Swelling Ankles or Feet Select AllMEDICAL HISTORY Place a mark on "Yes" or "No" to indicate if you have had any of the following:ADIS HIV(Required) Yes No Diabetes(Required) Yes No Psychiatric Care(Required) Yes No Allergies to Anesthetics(Required) Yes No Ear Problems(Required) Yes No Radiation Treatment(Required) Yes No Allergies to Medicine or Drugs(Required) Yes No Epilepsy(Required) Yes No Rash(Required) Yes No Anemia(Required) Yes No Eye Problems(Required) Yes No Respiratory Disease(Required) Yes No Angina(Required) Yes No Foot or Leg Cramps(Required) Yes No Rheumatic Fever(Required) Yes No Arthritis(Required) Yes No Gout(Required) Yes No Shortness of Breath(Required) Yes No Artificial Heart Valves or Joints(Required) Yes No Headaches(Required) Yes No Sinus Problems(Required) Yes No Asthma(Required) Yes No Heart Disease(Required) Yes No Special Diet(Required) Yes No Back Problems(Required) Yes No Hemophilia(Required) Yes No Stroke(Required) Yes No Bleeding Disorders(Required) Yes No Hepatitis or Jaundice(Required) Yes No Swelling in Ankles, Feet(Required) Yes No Cancer(Required) Yes No High Blood Pressure(Required) Yes No Swollen Neck Glands(Required) Yes No Chemical Dependency(Required) Yes No Kidney Problems(Required) Yes No Tired Feet(Required) Yes No Chest Pain(Required) Yes No Liver Disease(Required) Yes No Tuberculosis(Required) Yes No Chronic Diarrhea(Required) Yes No Low Blood Pressure(Required) Yes No Ulcers(Required) Yes No Circulatory Problems(Required) Yes No Nervous Problems(Required) Yes No Varicose Veins(Required) Yes No Diabetes(Required) Yes No Phlebitis(Required) Yes No Venereal Disease(Required) Yes No Weight Loos unexplained(Required) Yes No Surgeries you have had:(Required)Hospitalization other than for the surgeries listed:(Required)Family physician:(Required) Date of Last Visit:(Required) Are you now or have you been. under any other doctor's care for any reason over the past two years?(Required) Yes No CONSENT I certify that the above information is true and correct to the best of my knowledge. I give my permission to the doctor to administer and perform such procedures as may be deemed necessary in the diagnosis and or treatment of my feet.Patient's Signature:(Required)Date(Required) MM slash DD slash YYYY Number(Required)
