PATIENT INFORMATION

Patient's Name (Last, First):

Date of Birth:

Name you prefer to be called (Mr. Smith, Mrs. Jones, Bob, etc):

Gender:

Male Female

Patient's Address:

City, State, Zip:

E-mail address:

Home Phone Number:

Cell Phone Number:

Social Security #:

Driver's License:

Occupation:

How did you hear about our practice/ whom may we thank for referring you?

Google Yelp Doctor Existing Pt

Other:

SPOUSE/ PARENT/ GUARDIAN INFORMATION

Name (Last, First):

Date of Birth:

Phone Number:

EMERGENCY CONTACT (If Different from Guarantor)

Name:

Relationship:

Phone #:

PHARMACY INFORMATION

Pharmacy Name:

Phone #:

Address:

City, State, Zip:

I hereby authorize Dr. Charles Baik and his associates to examine, photograph, administer treatment, and to perform such minor operative procedures as may be deemed necessary in the diagnosis and/or treatment of my foot/ankle problem.
l assign the right to payment for all medical benefits directly to Dr. Charles Baik in consideration for medical services and supplies provided pursuant to my health insurance plan.
I give consent to Dr. Baik to release medical information to other healthcare providers for the purpose of treatment, when necessary for my care. I give consent to Dr. Baik to send medical information, as necessary to my insurance plan. l agree that a photo copy of this form may be used in lieu of the original.
l certify the patient information form is true and correct to the best of my knowledge. l will notify you of any changes in my health status or the above information.

Date: