Intake Package New Patient
PERSONAL DETAILS
Your personal details. Please review them and make any necessary adjustments.
PAYMENT AND INSURANCE INFORMATION
FOOT HEALTH HISTORY
MEDICAL HISTORY
MEDICATIONS
ALLERGIES
SURGERIES
SOCIAL HISTORY
SIGNATURE ON FILE AND PERMISSION TO TREAT

I understand that the information provided on this form is true and correct to the best of my knowledge.

I authorize any holder of information about me to released any information needed to determine these benefits or the benefits payable to related services to the insurance agent.

I recognize my financial obligation of any coinsurance, co-pay or deductible and non-covered services that may be required.

I hereby give permission to Rainville Health qualified staff to evaluate, diagnose and treat&edsp;&edsp;my foot related condition as may be deem necessary.

I attest that I am receiving treatment at Rainville Health because I want to get better.