Patient Name:(last, first, mi)___________________________________________________ Address: ___________________________________________________________________ City: ____________________ State: _______________________ Zip Code: ____________ Home Phone #: _____________________ Work/Cell Phone: __________________________ Date of Birth: ________________ Age ______ Social Security #: _______________________ Marital Status: (Circle) S     M     D     Sep     W       Sex: M     F         Fax: ______________ Patient's Employer: ___________________________ Occupation: _____________________ Employer's Address: __________________________________________________________ Spouse's Employer: _____________________________ Phone #: _____________________ Employer's Address: __________________________________________________________ Name of Relative or contact in case of emergency: __________________________________ Phone #: ___________________ Address: ________________________________________ Referral Source : ____________________________________________________________ Person responsible for payment: __________________ Relation to patient: _____________
Are you under physician's care now for any reason? yes ______ no ______ Name of Physician: ___________________________ Phone #: _____________________
I hereby give Dr. Peter DeFrank permission to examine and treat my feet. I AUTHORIZE DR. PETER R. DEFRANK TO RELEASE ANY MEDICAL INFORMATION ABOUT ME, NECESSARY TO PROCESS CLAIMS FOR PAYMENT, FOR THE PERFORMANCE OF HIS SERVICES. A 24 HOUR CANCELLATION NOTICE IS REQUIRED OR AN OFFICE VISIT WILL BE CHARGED.
Patient's Signature ________________________________ Today's Date _______________ I have read, understand and agree to the above terms.
Dr. Peter R. DeFrank - Dallas Foot Care Center
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