Intake Form Patient InformationPatient Name(Required) First Last Patient Date of Birth(Required) MM slash DD slash YYYY Patient Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Age(Required)Please enter a number from 1 to 130.Height(Required) Weight(Required)Shoe Size(Required)Have you ever been treated by a Podiatrist?(Required) Yes No Not Sure If yes, last date seen(Required) MM slash DD slash YYYY Do you smoke?(Required) Yes No Have you been treated by a Specialist?(Required) Yes No Not Sure If yes, for what condition(s)(Required) Past Medical History (check all that apply) Ulcers Diabetes Heart Disease Circulation Problems Kidney Disease Dialysis Neuropathy High Blood Pressure Cancer Lung Disease Thyroid Disease Stoke Pneumonia Other Additional Medical History(Required)Medications (click the plus button to add additional medications)NameDoseHow Often TakenPrescribed/Over the Counter Add RemoveAllergies (click the plus button to add additional allergies) Add RemoveCurrent Chief Complaint(Required)Please Provide All Insurance Information Physician InformationPrimary Care Physician(Required) Physician Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Physician Phone(Required)Last Date Seen(Required) MM slash DD slash YYYY Consent AuthorizationsResponsible Party Name First Last Description of Personal Representative's Authority(Required) TREATMENT AUTHORIZATION & CONSENT TO RELEASE PRIVATE HEALTH INFORMATION:(Required) As the Responsible Party, I agree to these terms.I hereby authorize treatment by We Heel The Sole Podiatry, LLC. I understand that my healthcare information is private and that my insurance carrier will require this information in order to process claims for payment of services rendered by this medical provider. I authorize the release of pertinent medical information to my insurance carrier(s). I also authorize payments to be made directly to this medical provider by my insurance carrier(s).Patient Consent for Use and Disclosure of Protected Heath Information(Required) As the Responsible Party, I agree to these terms.I hereby give my consent for We Heel the Sole Podiatry, LLC to use and disdose protected health information (PHI) about me to carry out treatment, payment and health care operations (TPO). (The Notice of Privacy Practices provided by We Heel the Sole Podiatry, LLC describes such uses and disclosures more completely.}MEDICARE AUTHORIZATION(Required) As the Responsible Party, I agree to these terms.Irequest that payment of authorized Medicare benefits and, if applicable, Medicaid benefits, be made either to me or on my behalf to We Heel the Sole Podiatry, LLC for any services furnished to me by that provider. To the extent permitted by law, I authorize any holder of medical or other information about me to release to the Centers for Medicare and Medicaid Services, and their agents any information needed to determine these benefits or benefits related services.PERMISSION TO TREAT(Required) As the Responsible Party, I agree to these terms.Signing this form, I voluntarily give permission to Dr Jerwana Laster to provide Pediatric Medicine Care for the above patient This will include all treatment necessary for the care of the problem associated with the diagnosis found.