New patient intake

Please tell us a little about yourself so we can prepare for your visit. Everything you enter stays private and secure.

indicates a required field.

About you

Your name as it appears on your insurance card.

First name Middle name (optional) Last name

Suffix (optional) Date of birth Enter as month, day, year (for example, 05/18/1948).

Address

Where you live now — for our records and insurance verification.

Street address

City State ZIP code

Contact

How we’ll reach you about your appointment.

Phone number Email address

In case of emergency

Contact name Contact phone

Insurance

From your insurance card. If you have a second plan, add it below.

Primary insurance

Plan name Member ID

Secondary insurance (optional)

Plan name (optional) Member ID (optional)

Health questions

A few questions about your medical history.

Have you received diabetic shoes within this benefit year?

Yes No

Any amputations?

Yes No

Swelling or edema?

Yes No

Doctor treating your diabetes or lymphedema The provider who manages this condition for you.

Recent diabetic foot exam performed?

Yes No

If yes, who performed it? Name of the PA, CNP, MD, or DPM who did the exam.

You'll get one last chance to review your answers before submitting.

Please review your answers