Get Plaza Podiatry New Patient Intake Form

Filling out the Plaza Podiatry New Patient Intake Form online is a straightforward process that ensures all necessary information is collected for your first visit. This guide will provide you with step-by-step instructions to complete the form accurately and efficiently.

Follow the steps to fill out your intake form online.

1. Press the ‘Get Form’ button to access the intake form and have it open in your editing tool.
2. Begin by entering your full name in the designated field.
3. Indicate your gender by selecting the appropriate option (Male or Female).
4. Fill in your date of birth and age in the respective fields.
5. Provide your complete address, including city, state, and zip code.
6. Enter your home phone number, work phone number, and a cell phone number.
7. Choose your marital status from the provided options.
8. List an emergency contact along with their phone numbers.
9. Input your email address and primary spoken language.
10. Select your employment and student status by checking the applicable boxes.
11. Indicate your race and ethnicity by selecting the appropriate options.
12. Provide the name of your primary care physician and any specialists you may have seen.
13. Describe your foot or ankle problem in detail and note how long you have had the issue.
14. List any treatments you have received for the problem.
15. Complete the allergies section by checking any relevant allergies and detailing your reactions.
16. List all current medications and dosages in the medications section.
17. Check relevant medical conditions from your personal medical history.
18. Complete the surgical history section with any past procedures or significant health issues.
19. Answer questions regarding personal habits such as smoking and alcohol consumption.
20. Provide your height, weight, shoe size, and any additional information you think is necessary for your treatment.
21. Circle any current medical conditions that apply to you from the provided list.
22. Read and acknowledge the consent section, then provide your signature and date.
23. Finally, save your changes, download the completed form, print it, or share it as needed.

Complete your Plaza Podiatry New Patient Intake Form online today!