New Patient Intake – On 2 Feet

ON 2 FEET

Digital Patient Intake Portal

HIPAA Secure

Personal Medical Insurance Consent

Personal Identification

Please provide your basic contact and demographic information.

First Name

Last Name

Date of Birth

Gender

Email Address

Primary Phone

Last 4 digits of SSN

Residential Address

Street Address

City

State

Zip

Clinical History

Tell us about your podiatric issues and medical background.

Chief Complaint (Reason for visit)

Are you currently taking any medications?

Allergies

Medical History Checklist

Diabetes (Type I/II) Poor Circulation Arthritis Neuropathy/Numbness

Insurance & Emergency

Provide your insurance details and an emergency contact.

Primary Insurance Provider

Member ID #

Group #

Emergency Contact

Full Name

Relationship

Contact Phone

Consent & Signatures

Please review our clinic policies, acknowledge each, and sign below.

Patient Contract

I understand that I am being seen for podiatric issues. The care is known to be effective only when provided on a regular basis. Lapses in my treatment, or failure to comply with the plan of care can result in this therapy becoming less effective.

My responsibilities include:

Learning how to promote my own health and wellness.
Taking my medications as prescribed if prescribed.
Appearing for treatment as scheduled.
Notifying the office if contact information changes.
I understand that violation may result in discharge.

I have read and agree to the Patient Contract.

Cancellation Policy

A “No Show / Late Cancellation” is defined as missing an appointment without canceling at least 24 hours before the scheduled time. There will be a charge for missed or non-canceled appointments of $50.00.

I have read and agree to the Cancellation Policy.

Biological Specimen

By signing, you affirmatively decision to consent to the transfer of any and all biological specimens collected by or deposited with ON 2 FEET to a third party for disposal/cleaning (FL Stat 817.5655).

I consent to the Biological Specimen policy.

Patient Signature (Draw Below)

Please check the boxes to agree to all policies above before signing.

Intake Form Finalized

ON 2 FEET

Advanced Podiatry Hub

DOCUMENT ID: O2F-INTAKE-

1. Patient Identification

Full Name

Date of Birth / Gender

Contact

Last 4 SSN

Address

2. Clinical History

Chief Complaint

Medications

Allergies

Conditions Checklist

3. Insurance & Emergency

Primary Insurance

Member ID

Group Number

Emergency Contact

Relationship

Phone

By signing below, I acknowledge that I have reviewed and agree to the On 2 Feet Patient Contract, Cancellation Policy, and Biological Specimen policies. I certify that the information provided is accurate to the best of my knowledge.

Patient / Guardian Signature Date Signed

HIPAA Compliant Secure Intake Portal Record