NEW PATIENTS

HUMMEL FOOT AND ANKLE
Lindsay M. Hummel, DPM
161 Old Schoolhouse Lane
Mechanicsburg, PA 17055
717-691-8128

PATIENT INFORMATION

Name: __________________________________________  Male [  ]  Female [  ]

Address: _____________________________________ City/State/Zip: ____________________

Home Phone: ________________________ Cell Phone: __________________________

Email: __________________________ SSN: ________________________________

Date of Birth: ______________________________ Age: ___________

Employer Name: ________________________________ Occupation: ____________________

Work Telephone: _____________________________

Emergency Contact Name: ______________________________ Telephone: _______________

INSURANCE INFORMATION: Please fill out this information.
We will make a copy of your insurance card(s) for the policy numbers and other information we may need for the claim submission, however, please fill out the space below to help clarify information not on your card.

Name of Primary Insurance Co: ___________________________ ID#: ____________________

Subscriber’s Name: _______________________ Relationship: _____________ DOB: ________

Name of Secondary Insurance Co: _________________________ID#: ____________________

Subscriber’s Name: _______________________ Relationship: _____________ DOB: ________

REFERRAL

How did you hear about our office? [  ] Other Provider/Doctor [  ] Family Member [  ] Internet
[  ] Provider Directory [  ] Another Patient [  ] Other: __________________________________

What brings you to our office today? ______________________________________________

MEDICAL HISTORY

Family Physician: ___________________________ Address: ____________________________
Phone Number: __________________________

Preferred Pharmacy: ___________________________ Address: _________________________
Phone Number: ____________________________

Do you have a history of or currently have any of the following? (Check all that apply)

[  ]High Blood Pressure   [  ]Heart Attack   [  ]Heart Failure      [  ]Kidney Infections/Stones 

[  ]Thyroid Problems    [  ] Poor Circulation   [  ]Hepatitis   [  ]Stroke    [  ]Emphysema/COPD

[  ]Liver Disease/Disorder   [  ]Fibromyalgia  [  ]Blood Clots   [  ]Arthritis  [  ]Seizures  [  ]Diabetes

[  ]Gastric Ulcers    [  ]Asthma  [  ]GERD/Acid Reflux   [  ]Leg Cramps   [  ]Phlebitis/Varicose Veins

[  ]Autoimmune Disease/Disorder   [  ]Pacemaker/ICD    [  ]Use of Blood Thinners/Daily Aspirin

[  ]History of Organ Transplant   [  ] Joint Replacement. Which joint(s)? ____________________

[  ]Other Implant(s)/Hardware: ___________________________________

[  ]Cancer. Type: ____________________________ [  ]Neuropathy     [  ] Use of Chemotherapy

[  ]Other serious health issues or illnesses: __________________________________________

_____________________________________________________________________________

MEDICATIONS: Include prescriptions, over-the-counter medications, and supplements:

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

ALLERGIES AND REACTIONS: _____________________________________________________

SURGICAL HISTORY AND DATES: __________________________________________________

_____________________________________________________________________________

SOCIAL HISTORY:

Do you use tobacco? _______________________ Type? ____________________________ How much? _____________________

Do you drink alcohol? _________________________ How much? ___________________

Do you use recreational drugs? _____________________ Type? ___________________

ADDITIONAL INFORMATION: Please include any additional information as needed.

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

I HEREBY GIVE DR. LINDSAY HUMMEL PERMISSION TO EXAMINE/TREAT ME:

______________________________________   DATE:__________________________
    SIGNATURE OF PATIENT

_______________________________________ DATE: _________________________
  If a minor, signature of parent/legal guardian Printed name: ________________________

I HEREBY AUTHORIZE MY INSURANCE BENEFITS TO BE PAID DIRECTLY TO THE PHYSICIAN AND THAT I AM FINANCIALLY RESPONSIBLE FOR ANY NON-COVERED SERVICES. I ALSO AUTHORIZE THE PHYSICIAN TO RELEASE MY MEDICAL INFORMATION REQUIRED TO PROCESS THIS CLAIM.

__________________________________________ DATE: ____________________________
      SIGNATURE OF PATIENT

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

HUMMEL FOOT AND ANKLE – DR. LINDSAY M. HUMMEL, DPM

This form is used to obtain acknowledgement of receipt of our notice of privacy practices or to document our good faith effort to obtain the acknowledgement.

Name of patient (please print): _________________________________________________

Signature of patient: ______________________________________ Date: ______________

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*You may refuse to sign this acknowledgement. Please specify the exact reason why patient chose not to sign the acknowledgement of receipt of notice of privacy practices*

_________________________________________________________________________

_________________________________________________________________________

Signature/Title: ______________________________ Date: ________________

• Driver's license/form of identification

• Insurance card(s)

• New patient paperwork

• List of medications, supplements, and over-the-counter medications

• Footwear/orthotics that you wear on a regular basis or footwear/orthotics that you would like the doctor to review

• For diabetics: last HbA1c %, date last seen by primary care/family doctor

• The initial visit to the office is often the longest. You will be asked questions regarding your health/medical history, current concerns, medications, etc. You may be asked these questions multiple times throughout the visit to ensure all information is obtained -- this helps us help you!

• You will be welcomed by the front desk staff who will take your paperwork, ID, insurance cards, etc. and then you will be brought back to a treatment room where the medical assistant will ask you some preliminary questions.

• The doctor will be in to see you shortly after you arrive to the treatment room. She will ask questions, perform a comprehensive foot exam, discuss diagnoses/treatment options/follow up. Depending on the concern, she may recommend further testing such as x-ray (which can be performed on-site), MRI, CT, vascular testing, etc. She will answer any and all questions you may have -- your treatment plan will be a shared decision between you, your family and your doctor! If something confuses or concerns you, please let Dr. Hummel know.

• After your appointment is completed, you will be helped at the front desk with scheduling a follow up, testing scheduling,  and any other paperwork that may be required.

Although Dr. Hummel only performs small, in-office, soft-tissue procedures such as flexor tenotomies, biopsies, nail avulsions, small soft tissue mass removal, and wound care, there are still options for you! More extensive surgeries such as bunionectomies, hammertoe procedures, ankle procedures, etc. can be performed by a surgical podiatrist -- we actually share an office with Dr. Jeff Marks, who has 30+ years of experience and is a highly qualified foot and ankle surgeon!