Healthcare Podiatry Form

Healthcare Podiatry Form

Patient Information

Patient Name:

Date of Birth:    Gender: Male Female Other/Prefer not to say

Emergency Contact

Insurance Information

Medical History

Current Medications (include dose and frequency):

Allergies:

Prior Surgeries / Hospitalizations Related to Feet or Lower Extremities:

Chronic Conditions (check all that apply):

Reason for Visit / Symptoms

Consent for Treatment

I, the undersigned, authorize the podiatry clinicians and staff of this practice to provide evaluation, diagnostic testing, and treatment as necessary. Treatment may include physical examination, diagnostic X-rays, wound care, debridement, minor office procedures, corticosteroid injection, prescription of medications, and referrals to specialists when indicated.

I understand the potential risks and complications associated with podiatric care which may include, but are not limited to: infection, bleeding, delayed healing, worsening pain, allergic reaction to medications or materials, nerve injury, and rare systemic complications. I acknowledge that no guarantee can be made as to the results of treatment.

I have been given the opportunity to ask questions about my condition and proposed treatment and those questions have been answered to my satisfaction. I understand that I may revoke this consent at any time before a procedure or treatment is performed by notifying the clinician, but revocation will not affect actions already taken in reliance on this consent.

Financial / Billing Authorization

I authorize the release of any medical information necessary to process insurance claims and request payment of benefits to the treating provider. I understand that I am financially responsible for charges not covered by my insurer and for any co-payments, co-insurance, or deductibles as required by my plan.

Authorization to Use and Disclose Protected Health Information

I authorize the practice to use and disclose my protected health information for treatment, payment, and healthcare operations as described in the practice's privacy policies. I authorize the release of records, images, and reports to referring providers, treating facilities, and insurance payors for continuity of care and claims processing.

This authorization will remain in effect until the following date: . If no date is entered, authorization will remain valid until revoked in writing.

Release of Photographs and Records

I consent to photographs, digital images, or video recordings of treatment sites for medical documentation, diagnosis, and treatment planning. Such images become part of the medical record and may be used for teaching or quality assurance unless I specifically restrict their use in writing.

Patient Rights and Acknowledgment

I acknowledge receipt of the practice's Notice of Privacy Practices and understand my rights with respect to my protected health information. I understand that I may request restrictions on certain uses and disclosures, and that I may inspect and request copies of my medical record consistent with applicable law.

Additional Consents / Miscellaneous

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