Please Print
Name _________________________________________________________________ Date of Birth ______/______/________
           First                              Middle                       Last
Sex:     Male ____   Female ____    Married ____   Single ____   Widowed ____   Divorced/Separated ____
Home Address ______________________________________________ Apt No _______ SS# __________________________
                         Number            Street
City ______________________________________________________ State ________ Zip  ___________________________
Home Phone ___________________ Work Phone _________________ Email Address   ________________________________
Patient Occupation __________________________________ Employer ____________________________________________
Employer Phone  ____________________________________
If patient is a child or dependent adult, please give name of responsible party for finances and billing
Responsible Party ________________________________________________ Date of Birth _________/______/____________
Responsible Party Employer ________________________________________ Phone  _________________________________
Insurance Information
(   )  Check here if NO health insurance
Primary Carrier ____________________________________    Policy Holder Name _____________________________
     (If other than patient)
Policy Holder SS#  ____________________________________    Group # ____________________ ID #  _______________
Relationship to insured:    Self _____   Spouse _____   Child ______
Secondary Carrier  _______________________________    Policy Holder Name _____________________________
     (If other than patient)
Policy Holder SS#  ____________________________________    Group # ____________________ ID #  _______________
Relationship to insured:    Self _____   Spouse _____   Child ______
Were you referred to this office? By Whom? __________________________________________________________________
Referring Doctor __________________________________________________ Phone ________________________________
How did you hear about our office?  _________________________________________________________________________
Is this a compensation or work-related case? Yes ____ No ____ Date of Accident _____________________________________
Briefly describe foot problem  ______________________________________________________________________________

Signature ____________________________________________________________ Date _____________________________
Driver's License Number ___________________________________ Relationship to Patient  ____________________________



PAST MEDICAL HISTORY
Today's Date_____________
Name _______________________________________________________ Sex _______ Date of Birth _______/_____/_______
Age ________ Height __________ Weight __________ Shoe Size __________
Occupation _____________________________________________________________________________________________
Chief Complaint  _________________________________________________________________________________________
 ______________________________________________________________________________________________________
Onset:   Sudden _____   Gradual ______   Previous Fractures/Dislocations _____________________
Current Health:   Good  ______   Fair  ______   Poor  ______
Currently Seeking Medical Care:   Yes  ______   No  ______   Why ____________________________
______________________________________________________________________________________________________
(    ) Diabetes    (    ) Seizure Disorders    (    ) Heart Trouble    (    ) Arthritis
(    ) Circulatory Disease    (    ) Hypertension (High B/P)    (    ) Kidney Trouble    (    ) Asthma
(    ) Bleeding Disorders    (    ) Hypotension (Low B/P)    (    ) Liver Disease    (    ) Epilepsy
(    ) Rheumatic Fever    (    ) Nervous Condition    (    ) Hepatitis    (    ) Stroke
(    ) Stomach Ulcers    (    ) Sickle Cell Anemia    (    ) Skin Problems    (    ) Gout
(    ) HIV    (    ) Pregnant    Other: _______________________________________
Allergies:
(    ) Foods    (    ) Sulphites    (    ) Iodine
(    ) Aspirin    (    ) Sulphur    (    ) Tape
(    ) Codeine    (    ) Local Anesthesia    (    ) Other:                                   
(    ) Penicillin    (    ) Novocain    ________________________________________
              ________________________________________
Past Surgical History
Surgery    Date    Surgery    Date
____________________________    _____________    ____________________________    ____________
____________________________    _____________    ____________________________    ____________
____________________________    _____________    ____________________________    ____________
Present Medications
Medications    Illness    Medications    Illness
____________________________    _____________    ____________________________    ____________
____________________________    _____________    ____________________________    ____________
____________________________    _____________    ____________________________    ____________
Family History:   (   )  Diabetes   (   )  Hypertension    (   )   Bleeding Disorder  (   )  Circulatory   (   )  Arthritis   
                           (   )  Problem with Anesthesia
Social History:   Tobacco (Pks/Day)  ______   Coffee/Tea (Cups) ______   Alcohol ______
Do you take aspirin regularly? ______   Do you faint easily? ______________



INSURANCE AUTHORIZATION/PAYMENT POLICY

Assignment and Release
I, the undersigned, certify that I (or my dependent) have insurance coverage with the above named insurance company(ies), and assign directly to Dr. Mantzoros/Dr. Gordon all insurance benefits. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions:

________________________________________ Date _______________________________
Responsible Party Signature

Medicare Authorization (If Applicable)
I request that payment of Medicare benefits be made on my behalf to Dr. Mantzoros/Dr. Gordon for any services furnished me by that physician. I authorize any holder of medical information needed to determine these benefits or the benefits payable for related services. I understand my signature requests that payment be made and authorizes release of medical information to pay the claim. If "other health insurance" is indicated in Item 9 of the HCFA-1500 form, or elsewhere on other approved claim forms or electronically submitted claims, my signature authorizes releasing of the information to the insurer or agency shown. In Medicare assigned cases, the physician or supplier agrees to accept the charge determination of the Medicare carrier as the full charge, and the patient is responsible for only the deductible, coinsurance, and non-covered services. Coinsurance and the deductible are based upon the charge determination of the carrier.

________________________________________ Date ______________________________

Payment Policies
All copays, deductibles, and coinsurance are due at the time of service. If you belong to an HMO, you will need a referral. If you belong to a PPO, you may have a deductible. Remember, it is your responsibility as a patient to get a referral if one is required. If you do not have one, you will be responsible for out-of-network benefits. Please let the receptionist know if you have new insurance at your time of arrival.

Insurance Release/Authorization
I understand that for medical/legal purposes and by Texas State Law, X-rays and medical records taken/created by this office are the property of Dr. Mantzoros and Dr. Gordon. I also understand that all charges for services are due and payable at the time the services are rendered. We accept cash, checks, Mastercard, Visa and Discover.

I agree to be responsible for the charges on this account.

______________________________________ Date _____________________________
Patient or Guardian
 
 
 

CONROE FOOT SPECIALIST
DR. D. S. MANTZOROS, D.P.M.
DR. M. L. GORDON, D.P.M.
DR. S. FAYSAL. D.C.

DATE______________________________

I, __________________________________, herby authorize the staff of Dr. Mantzoros, Dr. Gordon, and Dr. Faysal to disclose information to the following person(s) about my procedures, as well as any other information concerning my health. I also authorize the following person(s) to receive information concerning my financial statement.

Name Relationship Date Initial
1. ___________________ ______________ ___________ ____
2. ___________________ ______________ ___________ ____
3. ___________________ ______________ ___________ ____
4. ___________________ ______________ ___________ ____
5. ___________________ ______________ ___________ ____

PLEASE NOTE:

There will be times this office will call and leave messages regarding appointments and/or procedures.
This will be effective until I, _________________________, put in writing that I withdraw the above listed person(s).

___________________________________ ____________________
Signature                                                            Date