Intake Package New Patient
PERSONAL DETAILS
Your personal details. Please review them and make any necessary adjustments.
How would you like us to contact you for the following:
What prompted you to make an appointment with us?
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 informationprovided on this form is true and correct to the best of my knowledge.

I request that payments of authorized benefits be made on my behalh for any services furnished by Rainville Health.

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 obligationof 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.