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Mikkel C. Jarman, DPM

DAIE: J J-

PATIENT NAME:

IAST FIRST MI

633 E. Ray Rd Suite 128

Gilbert, AZ 85296

ph: 480-197-3916

fx: 480-497-3947

DATE OF BIRTH: / /- SEX: M F

crrY/srATE/ztP:

PREFERRED PHONE NI.JMBER:

ALTERNATE PHONE NUMBER:

HOME ADDRESS:

EMAIL ADDRESS:

MAY WE TEAVE A MESSAGE? :YES NO

MAY wE LEAVE A MESSAGE? :YES NO

TEXT REMINDERS: YES NO

PRIMARY LANGUAGE: HOW DID YOU HEAR ABOUT US?

PARENT INFORMATION:

elEASEltECtE-grE e$ASECIBCIESSE

MOTHER STEP.MOTHER LEGALGUARDIAN FATHERSTEP.FATHERLE6ALGUARDIAN

NAME: NAME:

CE LL#:

WORK#: WORK#:

DATE OF BIRTH:-/EMPLOYER:

DATE OF BIRTH; / /EMPLOYER:

EMERGENCY CONTACT INFO:

NAME/PHONE#:

NAME/PHONE#:

RELATIONSHIP:

RELATIONSHIP:

PEDIATRICIAN:

PHARMACY:

O FF ICE: PHON E:

PHONE:CROSS STREETS:

INSURANCE INFORMATION:

PRIMARY INSURANCE COMPANY:

ADDRESS: clTY/STATE/ZrP

GROUP#MEMBER ID#:

POLICY HOLDER NAME: DoB:JJ_RELATIONSHIP TO PATIENT:

SECONDARY INSURANCE COMPANY:

ADDRESS: CITY/STATE/ZIP

GROUP#MEMBER IDf :

POLICY HOLDER NAME:

RELATIONSHIP TO PATIENT:

DoB: J_J_

PATIENT NAME:

DOB: J--------.,1-MEDICAT HISTORY

PLEASE LIST ALL KNOWN ALLERGIES:

CURRENT DAITY/SEASONAL MEDICATIONS AND DOSAGE:

CRAWL:

WHAT AGE DID YOUR CHITD:

I STAND: IWALK:

REASON FOR VISIT:

WHEN DID PROBTEM FIRST START?: DURATION OF PROBIEM:

LIST ANY PRIOR TREATMENTS FOR THIS PROBTEM:

tr CEREBRAL PALSYCONGENTIAL

HEART DISEASE

tr HEART MUMUR

INFECTION BONE

/ JOrNT

tr SEIZURES/EPILEPSY

IF APPLICABLE, HOW DOES YOUR CHILD DESCRIBE THEIR PAIN? PLEASE CIRCLE:

SHARP/ DUtt/ACHING / BURNINC / RADIATING / ITCHING / STABBING

OTHER:

PATIENTS NAME:

DoB:JJ-

PTEASE CIRCTE ONE:

PROBLEM CAUSED BY INJURY? YES / NO

DOES PROBLEM AFFECT ABILITY TO PARTICIPATE IN SPORTS/ACTIVITIES? YES / NO

WHAT MAKES PAIN FEEL WORSE? STANDING / WALKING/ RUNNING

SINCE THE PROBLEM STARTED HAS PAIN: STAYED THE SAME / EECAME WORSE / IMPROVED

USING DIAGRAM BELOW, CIRCTE WHERE PAIN/PROBLEM IS TOCATED:

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TO THE BEST OF MY KNOWLEDGE, I HAVE ANSWERED THE QUESTIONS ON THIS FORM

ACCURATELY. I UNDERSTAND THAT PROVIDING INCORRECT INFORMATION CAN BE DANGEROUS

TO MY CHILDS HEALTH. I UNDERSTAND THAT IT IS MY RESPONSIBILITY TO INFORM THE DOCTOR

AND OFFICE STAFF OF ANY CHANGES IN MY CHILDS MEDICAL STATUS OR HISTORY.

Printed Name of Porent/ Legal Guardion

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Signdture of Parent/ Legal Guardian Date

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633 E. Ray Rd. Suile 128

Gilbert, AZ 85296

ph: 180-497-3946

fx: 180-497-3947

receive may be non-

Any service

Mikkel C. Jarman, DPMBrcnt R lVeintrub, DPM

Thank you for choosing Preferred Foot & Ankle Specialists/Pediatric Foot and Ankle as your

preferred foot care provider. We are committed to provide you the best care possible. Your clear

understanding of the financial policy agreement is important. Please read carefully and initial and

sign where indicated. A copy will be provided for you upon request.

Illltlallgei As a courtesy we, Preferred Foot & Ankle Specialists/Pediatric Foot and Ankle will

verify your benefits. i!t!lM!eIg4le!& Coverage, benefits, and quotes given are not a guarantee of payment or coverage and

can change. lf your insurance company does not pay the practice within 50 days, the balance

owed will automatically be billed to you. lnitial: _

PJgg!3iltrg tl4$i We will bill your insurance with the information you provide us. Your failure

to provide us with the accurate information could result in claim denial. lf this occurs you assume

responsibility for the entire amount of the claim. lf we later receive payment from your

insurance, we will refund any overpayment. lf reouired. obtainins the oroper referral from vour

orimarv care phvsician is vour resoonsibilitv. Failure to have a valid referral, the patient will be

responsible to pay in full or reschedule appointment. lnitial: _

Co-oavs & Deductibles: All copays, deductibles and co-insurance amounts are due at time ofservice. We do not bill for co-pays. This arrangement is part of your contract with your insurance

company. Failure to collect any dues at time of service can be considered as fraud.lnitial:

EAy@!: Payment is expected at the time of your visit. Our office accepts cash, check, credit and

care credit. Payment will include any unmet deductible, coinsurance, copayment and non-

covered charges from your insurance company. After 90 days of non-payment accounts may be

subject to our collections process. lnitial:

lf special circumstances make immediate payment impossible, payment arrangements must beapproved in advance by our billing manager or patient care advocate.

Non-covered services: Please be aware that some or all of the services you

covered or not considered medically necessary by your insurance company.determined not covered by your plan will be your responsibility. lnitial:

eedb!4glalie$fi The accompanying parent or adult is responsible for any payment for copays,

deductibles, or coinsurance amounts at time of appointment. lnitial:

-

Mi$gtl4DlginlEgolsi We appreciate a 24-hour advance notice in any appointment cancellation

or reschedule. Failure to notify will result in a S25 dollar no show fee. Multiple no show or

cancellations could result in a S45 fee. lnitial:

Forms/Documents: Any FMLA/disability paperwork, and/or extra forms that are to be completed

by the providers will result in a S25 completion fee. This excludes any work notes/school notes.

lnitial:

I HAVE READ AND FUI.LY UNDERSTAND THE FINANCIAT POLICY SET FORTH BY PREFERRED FOOT

AND ANKTE SPECIATISTS/PEDIATRIC FOOT AND ANKtE. I AGREE THAT IF IT EECOMES

NECESSARY TO FORWARD MY ACCOUNT TO A COLTECTION AGENCY, I WItt AISO BE

RESPONSBILE FOR THE FEE CHARGED BY THE AGENCY FOR THE COSTS OF COTTECTIONS IN

ADDITION TO ORIGINAT AMOUNT DUE. I UNDERSTAND AND AGREE THAT THE TERMS OF THIS

FINANCIAL POTICY MAY BE AMENDED BY THE PRACTICE AT ANY TIME WITHOUT PRIOR

NOTIFICATION TO THE GUARANTOR,

Printed nome of potient or responsible party

Signoture of patient of rcsponsible pofty Date

ACKNOWLEDGEMENT OF RECEIPT

OF

NOTICE OF PRIVACY PRACTICES

I acknowledge that I was provided a copy the Notice of Privacy Practices and that I have read

them or declined the opportunity to read them and understand the Notice of Privacy Practices.

PRINT PATIENT,S NAME

Print Parent/Guardian Name

Signature Parent/Guardian

Pediatric Foot and Ankle maintains a confidentiality policy with all patient's medical

information. Please list the names of those that you give this office permission to share

information with concerning your child's medical condition.

hereby give permission for this office to share

information regarding my child's medical condition with the following:

lnitial Date

lnitial _ Date

lnitial Date

Signature Parent/Guardian

Consent for Treatment of Minor

Patient's Name:

Date of Birth: / I

l, the undersigned, parent/guardian of , a mlnor,

do hereby authorize and direct Pediatric Foot & Ankle to provide care.

Initials:

Consent from Parents or Guardians for Authorized Persons

As the biological parent or step parenl./guardian ofI am granting permission for the below listed person(s) to bring my child in for treatment

and or care.

PLEASE SELECT ONE OF THE FOLLOWING CHOICES:Initials - I am granting full permissions, meaning the below listed person(s) will

be allowed to agree to treatments, and know all health history pertaining to my child.

Initials - I am granting permissions, meaning the below listed person(s) is onlyallowed to bring my child in, and will have access to all health history, but not allowed to

agree to treatments without my direct consent.

_ Initials - I am granting limited permissions, meaning the below listed person(s)

is allowed to bring my child in to the office, but is not allowed access to any medical

information or treatment of my child. I will be informed of the visit results and I will be

notified prior to any treatment for my child.

Please list person(s) here

Consent to leave voicemailI am granting permission to Pediatric Foot & Ankle to leave phone messages

regarding my child's medical health to the number(s) provided on the registrationform. This consent will remain in effect until rescinded in writing.

Parent/Guardian Signature Date