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three best rated family foot center

New Patient Information


Please complete the following form and answer all questions before arriving for your appointment


Patient Information

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Family History (if so please indicate relationship)
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Insurance Information

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Emergency Contact

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Responsible Party

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I hereby authorize Jordana L. Szpiro, DPM to furnish information to insurance carriers concerning my illness and treatments, and I hereby assign to Jordana L. Szpiro, DPM all payments for medical services rendered to myself or my dependents. I am aware that it is my obligation to know my insurance company’s policies and that I am responsible for payments if I have not fulfilled their requirements. I hereby request and voluntarily consent to such office care, including routine diagnostic producers and medical treatment as may be deemed necessary by Jordana L. Szpiro, DPM and her designees.
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All co-payments and deductibles are due at the time of the visit and before you are seen by the doctor.
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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 chose) and understood the notice.
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AS PER YOUR CONTRACT WITH YOUR INSURANCE CARRIER YOU MAY BE RESPONISIBLE FOR A DEDUCTIBLE OR CO-INSURANCE.
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