Patient Registration Form

Please fill out the Medical History form completely.
You may also print this form and bring it with you durring your visit.

  • PATIENT INFORMATION
  • Check Preferred Method
  • Spouse Information (If Applicable)
  • INSURANCE INFORMATION
  • Pharmacy Information
  • Emergency Contact (If other than Spouse)
  • Guarantor Information: Complete if different from Patient
  • Guarantor Information: Complete if different from Patient
  • Do you have written authorization from your employer and comp carrier to be treated
  • Whom may we thank for sending you to our office?
  • I hereby authorize the release of any medical information pertaining to my treatment or information necessary for processing insurance claims and payment of medical benefits to myself or the party who accepts assignments. This authorization will remain valid until revoked by me in writing. I understand that I am legally responsible for all charges whether or not reimbursed by my insurance company.
  • MEDICARE SIGNATURE ON FILE
  • I request that payment of authorized Medicare benefits be made either to me or on my behalf of ANKLE AND FOOT INSTITUTE OF TEXAS for any services furnished me by the listed provider/supplier. 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 to related services.
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