Get Va Reston Podiatry Associates New Patient Form 2019-2025

Filling out the VA Reston Podiatry Associates New Patient Form online is a straightforward process designed to collect essential information needed for your initial consultation. This guide provides you with step-by-step instructions to ensure you complete the form accurately and efficiently.

Follow the steps to successfully complete the New Patient Form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the patient's first, middle initial, and last name. Also, indicate the patient's sex and provide the home address, including city, state, and zip code. Fill in home and cell phone numbers, email address, social security number, age, and date of birth.
3. Choose the patient's race and ethnicity from the provided options. Next, indicate marital status by selecting the appropriate option.
4. Input the patient's occupation and the employer's name along with the work phone number and employer address.
5. Specify the financially responsible person's details including their name, relationship to the patient, date of birth, and social security number. If this person has a different address than the patient, provide that address as well.
6. Provide information on the nearest relative not living with the patient, including their name, address, and contact numbers.
7. State how you were referred to the office.
8. In the chief concern/present illness section, clearly describe the current foot or ankle problem, specify which side it affects, and give details about the duration and any prior treatments.
9. Fill out the medical history section, including the family physician's name, any past physician care within the last two years, the date of the last physical exam, current medications, and any relevant health conditions.
10. Complete the family history and check any relevant treatments that have been received. Include any significant past surgical information.
11. Review the patient authorization section and provide your signature and date after confirming your understanding of the policies mentioned.
12. In the insurance information section, provide details on primary and secondary insurance coverage, including subscriber names, dates of birth, social security numbers, and employer information.
13. Lastly, review the form meticulously for accuracy before submitting. You can save the filled form, download it, print it, or share it as needed.

Complete your documents online to ensure a smooth and efficient visit to VA Reston Podiatry Associates.