Serving Chicagoland
and Surrounding Suburbs

Name: Mitchell Foot & Ankle
Address: 1424 E 53rd Street, Chicago, IL, 60615
Telephone: (773) 324-3338
Price range: $

Board Certified in Foot and
Reconstructive Rearfoot/Ankle Surgery

Test

Patient Registration Form

Full Name:

Birth Date:

Gender MaleFemale

Shoe Size:

SS#:

Age:

Marital Status: MarriedSingleOther

Patient Address

Address:

Apt#:

City:

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Zip:

Patient Contact

Home Phone:

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Email:

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Primary Insurance Information

Name of Insurance Company:

Primary Insured:

Birth Date:

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Secondary Insurance Information

Name of Insurance Company:

Primary Insured:

Birth Date:

Member ID:

Group #:

Physician Information

Primary Care Physician:

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Date of Last PCP Visit:

Hospital:

Name & Phone # of any other treating doctors:

Referral

Who should we thank for referring you?:

Emergency Contact:

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Reason for visit

Please describe for foot/ankle problem:

History

Name & Phone of Legally Responsible Person:

Special Considerations due to cultural or religious beliefs:

Language

Ethnicity Hispanic or LatinoNon Hispanic or LatinoDecline to answer

Smoking: NoYesQuit

How Often:

Yes - Type: CigarettesCigarsPipeChewing Tobacco

Alcohol: NoYesOccasional

Frequency:

Recreational Drug Use / Abuse: Denies UseAdmits Occasional Use

Caffeine YesNo

Type

Important Family History

Allergies

Medical Conditions

Significant Surgical & Invasive Prodecures

Medication List / Amount / Frequency

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 chose) and understand the notice.

I have received information on the Education and Training of Dr. Mitchell

I, also, authorize Mitchell Foot & Ankle, PC to release any of my chart information to the following person(s). spouse, mother, father, guardian, other relatives. etc.

Assignment and Release

I hereby give permission to Dr. Mitchell and his associates/staff to administer treatment as necessary, for the diagnosis and/or treatment of my foot and ankle condition.

I hereby authorize payment directly to Mitchell Foot & Ankle PC for services rendered by Dr. Mitchell and his associates/staff I understand and acknowledge that I am financially responsible for the entire services provided for myself or the above names. regardless of insurance coverage.

I authorize the above doctor and/or any provider or supplier of services in this office to release the information required to secure the payment of benefits I authorize the use of this signature on all insurance submissions.

Please Read and check the previous acknowledgements before submission

Mitchell Foot & Ankle

1338 E 47th St.
Chicago, IL 60653

Fax: 773-433-8108

(773) 324-3338
mfa@mitchellfootandankle.com

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Serving Chicagoland and Surrounding Suburbs

Test

Patient Registration Form

Patient Address

Patient Contact

Primary Insurance Information

Secondary Insurance Information

Physician Information

Referral

Reason for visit

History

Acknowledgement of Receipt of Notice of Privacy Practices

Assignment and Release

Please Read and check the previous acknowledgements before submission

Mitchell Foot & Ankle

Find Us On

Serving Chicagoland
and Surrounding Suburbs