Patient Forms Online

Cascade Foot and Ankle Clinic

Mark K. Williams, D.P.M., F.A.C.F.A.S and Abe Bagniewski, D.P.M.

Physicians and Surgeons of the Foot & Ankle

Step 1 of 5

Patient Information
Name of Patient*
First Last
Email
Today's Date*
MM slash DD slash YYYY
Address*
Street Address City State ZIP Code
Home Phone*
Work Phone
Date of Birth*
MM slash DD slash YYYY
Social Security Number
Sex*
Age
Shoe Size
Height IN INCHES
Enter numbers only.
Weight IN POUNDS
Enter numbers only.
Marital Status
Patient Employer
Occupation
Name of Emergency Contact
First Last
Relationship to Patient
Emergency Contact Phone Number
Minor Information
Are you a parent or legal guardian filling out this form on behalf of a minor?*
Name of Parent or Legal Guardian
First Last
Your Relationship to the Patient
Legal Guardian SSN
Insurance Information
Primary Insurance
Group Number
Subscriber Number
Name of Primary Subscriber
First Last
Subscriber's Birthdate
MM slash DD slash YYYY
Relationship to Patient
Will you be using secondary insurance?
Secondary Insurance
Group Number
Subscriber Number
Name of Secondary Subscriber
First Last
Secondary Subscriber's Birthdate
MM slash DD slash YYYY
Relationship to Patient
Physician Information
Primary Care Physician
Address
Street Address City State ZIP Code
Were you referred to our office by your primary care physician?
Assignment of Benefit
I hereby assign all medical and/or surgical benefits to which I am entitled, to the physician providing treatment, Mark K. Williams, D.P.M. FACFAS and/or Abe Bagniewski, D.P.M. This assignment will remain in effect until revoked by me in writing. A photocopy or print out of this assignment is to be considered as valid as an original. I understand that if I have insurance, I am financially responsible for charges whether or not they are covered by said insurance.
Signature
Please use your mouse or trackpad to create your legal signature within the dotted lines.
Today's Date
MM slash DD slash YYYY

General Health
Current Foot / Ankle Problems
Check All That Apply
Duration of Ingrown Nail Problem
Prior Treatment(s) for Ingrown Nails
Description of Your Ingrown Nail Problem (pain, swelling, redness, drainage, etc)
Duration of Bunion Problem
Prior Treatment(s) for Bunions
Description of Your Bunion Problem (pain, swelling, redness, drainage, etc)
Duration of Plantar Fasciitis
Prior Treatment(s) for Plantar Fasciitis
Description of Your Plantar Fasciitis Problem (pain, swelling, redness, drainage, etc)
Duration of Corns / Calluses
Prior Treatment(s) for Corns / Calluses
Description of Your Corns / Calluses Problem (pain, swelling, redness, drainage, etc)
Duration of Hammertoe Issues
Prior Treatment(s) for Hammertoe
Description of Your Hammertoe Problem (pain, swelling, redness, drainage, etc)
Duration of Neuroma Issue
Prior Treatment(s) for Neuroma Issue
Description of Your Neuroma Problem (pain, swelling, redness, drainage, etc)
Duration of Warts Issue
Prior Treatment(s) for Warts
Description of Your Wart Problem (pain, swelling, redness, drainage, etc)
Duration of Ankle Pain
Prior Treatment(s) for Ankle Pain
Description of Your Ankle Pain (pain, swelling, redness, drainage, etc)
Duration of Fracture
Prior Treatment(s) for Fracture
Description of Your Fracture (pain, swelling, redness, drainage, etc)
Duration of Issue Marked as Other or Unknown
Prior Treatments for Issue Marked as Other or Unknown
Describe the Issue Marked as Other or Unknown
Have you ever been treated by a podiatrist?
Date of Last Visit
MM slash DD slash YYYY
Female patients, are you currently:
Other relevant information we should know (Female Patients)
Have you recently experienced any of the following:
Select all that apply.
Eyes
Select all that apply.
Ear, Nose & Throat
Select all that apply.
Cardiovascular
Select all that apply.
Respiratory
Select all that apply.

Cascade Foot and Ankle Clinic

Step 1 of 5

Patient Information

Minor Information

Insurance Information

Physician Information

Assignment of Benefit

General Health

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