Online Patient Registration Form (Timberlane Foot Fairy)

Medical information profile

Patient Information
Name*
First Last
Date of Birth*
Please enter you date of birth MM-DD-YYYY
Address*
Street Address Address Line 2 City State ZIP Code
Social Security Number
Sex*
- Male
- Female
Marital Status
- Single
- Married
- Divorced
- Widowed
Student
- Yes
- No
Email Address
Home Phone
Cell Phone
Employer
Work Phone
Emergency Contact
Relationship
Emergency Contact Number
Referring Doctor
Primary Care Doctor
Condition/Body Part
I hereby agree and give my consent to medical treatment in treating my physical condition. I authorize release of any medical information needed to process my claim. I understand that I am responsible for any charges that are not covered by my insurance carrier. Furthermore, I understand that I am responsible to inform the office of any changes that occur. I authorize release of payment directly to Timberlane Foot Fairy regardless of participation in or out-of-network. Should I default on my financial responsibility and collection action is necessary, I will be responsible for collection costs that are incurred.
Patient/Parent/Guardian Signature*
Please read the disclosure and sign
Date
MM slash DD slash YYYY
Primary Insurance
Insurance Company
Group Number
ID Number/Claim Number
Answer if Policy Holder is different from Patient
Policy Holder
Policy Holder’s Date of Birth
Please enter you date of birth MM-DD-YYYY
Policy Holder’s SSN
Sex
- Male
- Female
Relationship to Patient
Address
Street Address Address Line 2 City State ZIP Code
If Auto or Worker’s Comp
Adjuster/Caseworker’s Name
Adjuster/Caseworker’s Phone
Secondary Insurance
Insurance Company
Group Number
ID Number/Claim Number
Answer if Policy Holder is different from Patient
Policy Holder
Policy Holder’s Date of Birth
Policy Holder’s SSN
Sex
- Male
- Female
Relationship to Patient
Cancelled Appointments
It is important for patients to keep all of their scheduled appointments, in order to be successful in reaching their treatment goals. With that in mind, I have developed the following cancellation policy.

Any appointment that you cannot attend must be cancelled with 48 hours notice. If the requested notice is not given there will be a charge of $75.

Missed appointment charges are not billable to medical insurance plans and will be the patient’s responsibility. Payment for missed appointments must occur before the next scheduled appointment; if no future appointments are scheduled then a bill will be mailed to you and must be paid upon receipt. No further appointments will be scheduled if you have an outstanding no-show fee. I do not have an administrative assistant, and will not be able to fill a last-minute cancellation or no-show; this fee covers my costs for the time set aside for your treatment.

Please remember that my objective is to help you meet your physical therapy and functional goals. It is essential to keep your scheduled appointment for a positive outcome.

By my signature below, I acknowledge that I have read and will abide by this Cancellation Policy.
Patient or Guardian Signature*
Please read and sign disclosure
Date*
MM slash DD slash YYYY
Designated Individuals Authorization Form
I hereby authorize on or all of the designated parties below to request and receive the release of any protected health information regarding my treatment, payment or administrative operations related to treatment and payment. I understand that the identity of designated parties must be verified before the release of any information.

Authorized Designees
Emergency Contact Name
Relationship
Name
Relationship
Name
Relationship
Patient Name
Signature
Notice of Privacy Policy
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Uses and Disclosures of Health Information

Timberlane Foot Fairy is required by law to protect the privacy of your personal health information, provide this notice about our information practices and follow the information practices that are described herein. Timberlane Foot Fairy uses your personal health information primarily for treatment; obtaining payment for treatment; conducting internal administrative activities and evaluating the quality of care that we provide. Timberlane Foot Fairy may also use or disclose your personal health information without prior authorization for public health purposes, for auditing purposes, for research studies and for emergencies. We also provide information when required by law in any other situation. Timberlane Foot Fairy’s policy is to obtain your written authorization before disclosing your personal health information. If you provide us with a written authorization to release your information for any reason, you may later revoke that authorization to stop future disclosures at any time. Timberlane Foot Fairy may change its policy at any time. When changes are made, a new Notice of Information Practices will be posted in the waiting room and patient exam areas and will be provided to you on your next visit. You may also request an updated copy of our Notice of Information Practices at any time.

Patient’s Individual Rights

You have the right to review or obtain a copy of your personal health information at any time. If you request photocopies of your personal health information, we may charge you $0.25 per page for these copies. You have the right to request a list of instances where we have disclosed your personal health information for reasons other than treatment, payment or other related administrative purposes. You may request in writing that we do not disclose your personal health information for treatment, payment and administrative purposes except when specifically authorized by you, when required by law or in emergency circumstances. Timberlane Foot Fairy will consider all such requests on a case-by-case basis, but the practice is not legally required to accept them.

Concerns and Complaints

If you are concerned that Timberlane Foot Fairy may have violated your privacy policy rights or if you disagree with any decision we have made regarding access or disclosure of your personal health information, please contact our practice manager at the address listed. You may also send a written complaint to the U.S. Department of Health and Human Services. For further information on Timberlane Foot Fairy’s health information practices or if you have a complaint, please contact the following:

Timberlane Foot Fairy ATTN: Jennifer Simpson 321 Main St • Suite D • Winooski, VT 05404

I acknowledge that I have seen the “Notice of Privacy Practices”. I understand that I may ask questions about the “Notice of Privacy Practices” at any time.
Patient or Guardian Signature*
Please read and sign disclosure
Date Signed*
MM slash DD slash YYYY
Medical Screening Questionnaire
Name
First Last
Today's Date
MM slash DD slash YYYY
Height
Enter Feet - Inches
Weight
Weight in pounds
Are you latex sensitive?
- Yes
- No
- Not Sure
Do you have a pacemaker?
- Yes
- No
Do you smoke?
- Yes
- No
Have you fallen recently?
- Yes
- No
FOR WOMEN: Are you currently pregnant or think you might be pregnant?
- Yes
- No
ALLERGIES: List any medication(s) you are allergic to
Have you RECENTLY noted any of the following (check all that apply)?
- Numbness or Tingling
- Muscle Weakness
- Dizziness/Lightheadedness
- Heartburn/Indigestion
- Difficulty with walking balance
- Changes in bowel or bladder function
- Fatigue
- Fever/Chills/Sweats
- Nausea/Vomiting
- Weight Gain/Loss
- Difficulty Swallowing
- Shortness of Breath
- Constipation
- Diarrhea
- Falls
- Fainting
- Cough
- Headaches
Have you EVER been diagnosed with any of the following conditions (check all that apply)?
- Depression
- Heart Problems
- Chest Pain/Angina
- Chemical Dependency (ie. Alcoholism)
- Circulation Problems
- Blood Clots
- Multiple Sclerosis
- Eye Problem/Infection
- Bone or Joint Infection
- Sexually Transmitted Disease/HIV
- Thyroid Problems
- Lung Problems
- Tuberculosis
- High Blood Pressure
- Rheumatoid Arthritis
- Other Arthritic Condition
- Bladder/Urinary Tract Infection
- Kidney Problem/Infection
- Pneumonia
- Pelvic Inflammatory Disease
- Cancer
- Diabetes
- Osteoporosis
- Stroke
- Epilepsy
- Asthma
- Anemia
- Anemia
- Liver Problems
- Hepatitis
Has anyone in your immediate family (parents, brothers, sisters) EVER been diagnosed with any of the following conditions (check all that apply)?
- Cancer
- Heart Problems
- High Blood Pressure
- Diabetes
- Thyroid Problems
- Depression
- Tuberculosis
- Stroke
- Blood Clots
During the past month have you been
Feeling down, depressed or hopeless?
- Yes
- No
Bothered by having little interest or pleasure in doing things?
- Yes
- No
If yes to either, is this something with which you would like help?
- Yes
- Yes, but NOT today
- No
Please list any medications you are currently taking (INCLUDING pills, injections, and/or skin patches)
Have you ever taken steroid medications for any medical conditions?
- Yes
- No
Have you ever taken blood thinning or anticoagulant medication for any medical condition?
- Yes
- No
Please list any surgeries or other conditions for which you have been hospitalized, including dates:
Please list all medications you are currently taking:
Medication name
Dosage
(amount in mg, ml, etc.)
Frequency
(how often)
Route of administration
(oral, injection, patch, etc.)
What date (roughly) did your present problems start?
My symptoms are currently
- Getting Better
- Getting Worse
- Staying about the same
Treatment received so far for this problem (chiropractic, injections, surgery, etc.):
Please list special tests performed for this problem (x-ray, MRI, labs, etc.)
My symptoms are currently
- Come and Go
- Are Constant
- Are constant, but change with activity
Using the 0 to 10 scale, with 0 being “no pain” and 10 being the “worst pain imaginable” please describe
Your current level of pain while completing this survey
The best your pain has been in the past 24 hours
The worst your pain has been in the past 24 hours
Easing Factors: Identify up to 3 important positions or activities that make your symptoms better
Aggravating Factors: Identify up to 3 important activities that you have difficulty with due to injury
How are you currently able to sleep at night due to your symptoms?
- No problem sleeping
- Difficulty falling asleep
- Awakened by pain
- Sleep only with medication
When are your symptoms worst?
- Morning
- Afternoon
- Evening
- Night
- After Activity
When are your symptoms the best?
- Morning
- Afternoon
- Evening
- Night
- After Activity
Patient Signature
Body Chart
Please download and print the attached body chart PDF, then fill it out and bring the form with you to your appointment.

Click to Download Body Form PDF
Comments
This field is for validation purposes and should be left unchanged.

Online Patient Registration Form (Timberlane Foot Fairy)

Patient Information

Primary Insurance

Answer if Policy Holder is different from Patient

If Auto or Worker’s Comp

Secondary Insurance

Answer if Policy Holder is different from Patient

Cancelled Appointments

Designated Individuals Authorization Form

Authorized Designees

Notice of Privacy Policy

Uses and Disclosures of Health Information

Patient’s Individual Rights

Concerns and Complaints

Medical Screening Questionnaire

During the past month have you been

Please list all medications you are currently taking:

Using the 0 to 10 scale, with 0 being “no pain” and 10 being the “worst pain imaginable” please describe

Body Chart

Please download and print the attached body chart PDF, then fill it out and bring the form with you to your appointment.