New Patient Packet

Dr. Latika Hinduja
3578 Brodhead Rd.Monaca, Pa 15061
Phone:724.774.6168
Fax: 724.775.2633

Patient First Name

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Patient Last Name

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Today's Date

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Patient Chart Number

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What is bringing you to see the doctor today?

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General Health

Height

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Weight

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lbs. Shoe Size:

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Arthritis

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Tuberculosis

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Mitral Valve Prolapse (Heart Murmur)

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Cardiac Disease

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Scarlet Fever

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Breathing Problems

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Breathing Problems (explain:)

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Hypertension (High Blood Pressure)

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Venereal Disease

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Peripheral Vascular Disease(Circulation)

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Hemophilia (Bleeder)

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Gout

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Stomach Problems

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Cerebral Accident (Stroke)

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Renal / Kidney Disease

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Diabetes

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Diabetes (Type:)

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Polio

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Liver Disease

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Cerebral Palsy

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HIV Positives (AIDS)

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Muscular Dystrophy

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Blood Tranfusion

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Blood Tranfusion (When)

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Phlebitis / Thrombophlebitis (Clot)

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MRSA

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Anemia (Blood Disorder)

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Thyroid Disease

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Slow Healer

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Other

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Surgical History

Please list ALL surgical interventions.

Surgical History

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Personal History:

Tobacco Use:

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How Often?

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How Long? (Years)

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Alcohol Use:

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How Often?

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How Long? (Years)

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Recreational Drug Use:

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How Often?

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How Long? (Years)

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Are you taking any medications?

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If Yes, please list below: (or provide us with a copy of list)

(Please include your prescription medication, vitamins, birth control pills, herbs, and any over-the-counter medications)

Medication

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Allergies and Reactions:

Penicillin

Tetracycline

Aspirin

Foods(Please Specify)

Adhesives

Sulfa Drugs

Novocain

Codeine

Caffeine

Barbiturates

Cortisone

Other

Environmental(Please Specify)

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Consent For Treatment

The above information is correct to the best of my knowledge and consent to such diagnosis procedures(including x-rays) and medical care and treatment as deemed necessary by Dr. Latika Hinduja.

Signature of Patient or Guardian:

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Date

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Signature of Witness:

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Date

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Sex:

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Birth Date

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Marital Status

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Social Security Number

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Home Address:

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City

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State

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Zip Code

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Email Address

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Home Phone Number

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Cell Phone Number

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If the patient ia a minor, please gice the name of parent or guardian who is financially responsible for billing.

Name of spouse/parent:

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Birth Date:

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Spouse's / Parent's Employer:

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Employer Address:

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City

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State

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Zip Code

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Employer Phone Number

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EXT

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Patient's Occupation:

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Patient's Employer:

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Employer's Address:

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City

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State

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Zip Code

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Employer Phone Number

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EXT

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Other Information

Primary Care Physician(PCP):

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Address:

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City

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State

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Zip Code

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Primary Care Phone Number

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Have you ever received DME:

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(Walking Boot, Braces, Crutches, Cane, Walker, Shoes and/or Orthotics)

Primary Pharmacy Names:

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City:

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State:

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Zip Code:

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In Case Of EMERGENCY Contact

Name:

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Relationship:

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Home Phone Number:

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Cell Phone Number:

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Discussion Of Medical Information

List any individuals with whom we may discuss your medical care and diagnosis. (Please provide their birthday for them to have access to any confidential information)

Name:

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Relationship:

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Phone Number:

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Birth Date:

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Name:

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Relationship:

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Phone Number:

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Birth Date:

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Acknowledgement of Receipt of Notice of Privacy Practices

I acknowledge that I was provided a copy of the Notice of Privacy Practices and that I have read (or had the opportunity to read, If I so choose) and understand the notice.

THE FOLLOWING IS REQUIRED BY LAW: PLEASE READ CAREFULLY AND SIGN

Print Name

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I request and authorize Dr. Latika Hinduja to release any information to the Health Care Financing Administration, Medical Assistance and my insurance company required to process my healthcare claim for services rendered by Dr. Latika Hinduja. I understand my signature authorizes Dr. Latika Hinduja and staff to examine and treat me, including x-rays. I also understand payment for services ot items could be for federal and / or state laws.

I hereby request payment be made directly to Dr. Latika Hinduja, by authorizing Medicare, medical Assistance, and / or all other insurance companies for all services rendered through Dr. Latika Hinduja. i understand that I am pesonally responsible for all charges which Medicare, Medical Assistance, and / or any other insurance company may or may not pay, including but not limited to co-insurance, co-payments, deductibles and non-covered services. I agree to make payment in full within 30days of receipt of billing. Aged account balances may be forwarded for collection with additional fees being incurred. Finally, I understand and agree this authorization will remain in effect until the time I request, in writing, termination of this authorization.

NOTICE: If you receive podiatric care by another physician within the past 61 days, MEDICARE may not pay for these services, and you will be responsible.

Signature

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Date

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I request and authorize Dr. Latika Hinduja to release any information to the Health Care Financing Administration, Medical Assistance and my insurance company required to process my healthcare claim for services rendered by Dr. Latika Hinduja. I understand my signature authorizes Dr. Latika Hinduja and staff to examine and treat me, including x-rays. I also understand payment for services ot items could be for federal and / or state laws.

I hereby request payment be made directly to Dr. Latika Hinduja, by authorizing Medicare, medical Assistance, and / or all other insurance companies for all services rendered through Dr. latika Hinduja. i understand that I am pesonally responsible for all charges which Medicare, Medical Assistance, and / or any other insurance company may or may not pay, including but not limited to co-insurance, co-payments, deductibles and non-covered services. I agree to make payment in full within 30days of receipt of billing. Aged account balances may be forwarded for collection with additional fees being incurred. Finally, I understand and agree this authorization will remain in effect until the time I request, in writing, termination of this authorization.

NOTICE: If you receive podiatric care by another physician within the past 61 days, MEDICARE may not pay for these services, and you will be responsible.

NO SHOW FEES POLICY

WE DO UNDERSTAND THAT THINGS CAN HAPPEN UNEXPECTEDLY, AND SOMETIMES WE NEED TO CANCEL A SCHEDULED APPOINTMENT. PLEASE BE COURTEOUS AND GIVE US A CALL TO LET US KNOW THAT YOU WILL NOT BE ABLE TO MAKE IT. WE WILL BE MORE HAPPY TO RESCHEDULE YOUR APPOINTMENT.

IN THE EVENT THAT A NO CALL. NO SHOW IS MADE, YOU WILL BE CHARGED A NO SHOW FEE OF $50.00.

THIS IS SOMETHING THAT WE DO NOT LIKE TO DO, BUT IT IS NEEDED IN ORDER TO SCHEDULE OTHER APPOINTMENTS NEEDED OR AN EMERGENCY IN YOUR PLACE.

WE THANK YOU KINDLY FOR UNDERSTANDING.

Signature

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Date

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