Forms for New Patients

PATIENT INFORMATION QUESTIONNAIRE
At Twin Cities Foot and Ankle Clinic, we believe your time is valuable. That’s why we work hard to ensure that each of our appointments begins on time.
To facilitate this promptness, we ask that you complete a few essential forms prior to your visit. The information you provide in these forms helps us to better understand your situation and the symptoms you are presenting, which will aid in creating a care plan that is customized to your needs.
Having them completed beforehand also allows you the opportunity to contemplate each question and provide an accurate and thorough response, which will save time during your office visit.

FILL OUT THE FORM BELOW OR CLICK HERE FOR A PRINTABLE PATIENT INFORMATION QUESTIONNAIRE FORM

Patient Information

  • Date of Birth

  • Contact Preference

  • Race / Ethnicity

  • Home Address

  • Preferred Pharmacy

  • Friend or Relative for Emergency Contact

  • Physician Information

  • How Were You Referred To Our Office?

  • Insurance Information

    Bring insurance card(s) to every appointment.
  • Policy Holder Date of Birth
  • Policy Holder Date of Birth

  • Release of Medical Information

    If you would like us to be able to give medical information to somone other than yourself, please complete the following authorization. I authorize the physicians and staff of Twin Cities Foot & Ankle Clinic, P.A. to communicate with the following persons regarding my medical care:

  • If a name is not provided, Medical information will not be released to personal representatives.

  • Telephone communication/authorization to release information: I authorize Twin Cities Foot & Ankle Clinic, P.A. to leave the following information. Check all that apply.

  • Are you okay with us leaving info?
  • I am aware of the Twin Cities Foot & Ankle Clinic, P.A. Financial / No Show Policy. There is a $25.00 fee for no-show appointments. Initial to agree below.
  • I understand this authorization will be valid until revoked in writing.

  • Release of Medical Records

  • I, the undersigned patient and/or responsible party hereby jointly authorize this office, its agent and employees, to release and disclose all or any part of the patient’s medical records to any entity which is, or may be liable for all or part of the provider’s charges. I authorize the release of records necessary to assist in the reimbursement of benefits to which I may be entitled.

    I authorize the release and disclosure, via fax machine, of any and all of my medical records to any other entity including but not limited to, referring physicians, hospitals, or health care providers which may be of assistance, in the opinion of this office, in the providing for the treatment of the patient.

    I request and authorize that payment of Medicare/other insurance company benefits be made to Twin Cities Foot & Ankle Clinic, P.A. for any services furnished me by a provider of our clinic. Type your name below and this will be acknowledged as an electronic signature.

    I understand that I am responsible for complying with the rules and regulations of my insurance company regarding Referral and Prior Authorization requirements. I agree to pay Twin Cities Foot & Ankle Clinic, P.A. for all charges for services not covered by Medicare or any insurance payer.

  • MM slash DD slash YYYY

  • Notice of Privacy Practices

    I acknowledge that I have been given the opportunity to review and/or receive a copy of the information contained in the Notice of Privacy Practices for Twin Cities Foot & Ankle Clinic, P.A.
  • MM slash DD slash YYYY

Golden Valley

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Dr. Felton | Podiatrist
Dr. Felton
Dr. Sperling | Podiatrist
Dr. Sperling

CONTACT US

Office: 763-546-1718
Fax: 763-546-1943
Email: info@tcfoot.com

GOLDEN VALLEY

5851 Duluth St., Ste 101
Golden Valley MN, 55422

GENERAL OFFICE HOURS

Monday – Thursday
8:30 a.m. – 5:00 p.m.
Friday
8:30 a.m. – 12:30 p.m.

APPOINTMENT HOURS

Monday – Thursday
9:00 a.m. – 4:30 p.m.