Bucks Foot & Ankle Care
We are located within the office of Dr. Carl J. Mattia, DPM.
638 Newtown Yardley Rd | Commons West Suite 1-H | Newtown, PA 18940
Patient Forms
PATIENT INFORMATION FORM
Today’s Date: ____ / ____ / ______
Patient Information
Name: _______________________________________DOB: ____ / ____ / ______
Sex: ☐ Male ☐ Female
Marital Status: ☐ Single ☐ Married ☐ Widowed ☐ Divorced
Email: _________________________________________
Spouse/Partner Name: ____________________________ Email newsletters, reminders, statements: ☐ Yes ☐ No
Emergency Contact
Name: __________________________________________ Phone: __________________________________________
Address
Street: __________________________________________ City: ____________________ State: ______ Zip: __________
Home Phone: ____________________ Cell Phone: _____________________ Other: __________________________
Insurance Information
Primary Insurance
Are you the insured? ☐ Yes ☐ No
Subscriber Name: __________________________________ Relationship: ☐ Spouse ☐ Child ☐ Self ☐ Other
Phone:__________________________________________ Sex: ☐ Male ☐ Female DOB: ____ / ____ / ______
Address: _________________________________________ Policy ID: ________________________________________
Group ID: ________________________________________ Employer: _________________________________________
Secondary Insurance
Are you the insured? ☐ Yes ☐ No
Subscriber Name: __________________________________ Relationship: ☐ Spouse ☐ Child ☐ Self ☐ Other
Phone:__________________________________________ Sex: ☐ Male ☐ Female DOB: ____ / ____ / ______
Address: _________________________________________ Policy ID: ________________________________________
Group ID: ________________________________________ Employer: _________________________________________
Visit Information
How did you hear about our practice? ☐ Physician ☐ Internet ☐ Telephone Book ☐ Family ☐ Friend ☐ Other:____
Reason for visit today:
Result of accident or work injury? ☐ Yes ☐ No
How long has this bothered you? ☐1 ☐2 ☐3 ☐4 ☐5 ☐ Days ☐ Weeks ☐ Months ☐ Years
Treatments tried & effectiveness:
Pain level (1–10): ________
Pain quality: ☐ Dull ☐ Burning ☐ Constant ☐ Sharp ☐ Shooting ☐ Throbbing ☐ Tingling ☐ Other: ___________
ADDITIONAL DEMOGRAPHICS
Ethnicity: ☐ Hispanic/Latino ☐ Not Hispanic/Latino ☐ Declined
Race: ☐ Asian ☐ American Indian/Alaska Native ☐ Black/African American ☐ White ☐ Native Hawaiian/Pacific Islander ☐ Declined
Preferred Language: ___________
Pharmacy Name: __________________________________________ Pharmacy Phone: __________________________________________ Pharmacy Address: _________________________________________
Primary Care Physician: __________________________ Phone: __________________ Date Last Seen: __________________ Address: _________________________________________________
Referring Physician: __________________________ Phone: __________________ Date Last Seen: __________________ Address: _________________________________________________
Privacy Information Preferences
Exempt from public reporting? ☐ Yes ☐ No Send mail to address on file? ☐ Yes ☐ No Call phone number on file? ☐ Yes ☐ No Leave voicemail? ☐ Yes ☐ No Email reminders/newsletters? ☐ Yes ☐ No Email: __________________________________________
Who can we leave messages with? ☐ Wife ☐ Husband ☐ Daughter ☐ Son ☐ Other: __________________ Name(s): ________________________________________________
Vital Signs
Blood Pressure: __________________ Height: __________________ Weight: __________________ Shoe Size: __________________
Medications
☐ No Known Medications ☐ I take the following medications:
☐ No Known Allergies ☐ No Known Drug Allergies
1. Name: _____________________ Reaction: _____________________
2. Name: _____________________ Reaction: _____________________
3. Name: _____________________ Reaction: _____________________
4. Name: _____________________ Reaction: _____________________
Advanced Directives
☐ Living Will ☐ DNR ☐ Durable POA ☐ Surrogate ☐ None
History & Physical
Medical History
☐ Alcoholism ☐ Blood Disorders ☐ Circulation Problems ☐ Musculoskeletal ☐ Breathing Issues ☐ Liver ☐ Sleep Apnea ☐ Gout ☐ Allergies ☐ Heart Disease ☐ Asthma ☐ Heart Murmur ☐ Stomach/Bowel ☐ Depression ☐ Anxiety ☐ Mental Illness ☐ Kidney Disease ☐ Blood Clot ☐ High Cholesterol ☐ High Blood Pressure ☐ Cancer ☐ Hepatitis ☐ Diabetes (Type 1 / Type 2) ☐ HIV ☐ CVA ☐ Arthritis (specify): __________________________ ☐ Skin Disorders ☐ Stroke ☐ Other (specify): __________________________ Are you nursing? ☐ Yes ☐ No Are you pregnant? ☐ Yes ☐ No
Surgical History
☐ None ☐ Yes If yes, list procedures:
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Social History
Do you smoke? ☐ Yes ☐ No If yes, packs/day: ☐1 ☐2 ☐3 ☐4 ☐5 For how long? __________________
Vape use: ☐ Daily ☐ Occasionally ☐ Rarely ☐Never
Alcohol use: ☐ Daily ☐ Occasionally ☐ Rarely ☐Never
Substance abuse: ☐ Current ☐ Past ☐ Never Details: ______________________________________________________
Occupation: _______________________________________________
Exercise: ☐ No ☐ Yes — Type: __________________________________________
Family History
Indicate family member: ☐ Alzheimer’s ☐ Depression ☐ Arthritis ☐ Diabetes ☐ Bleeding Disorders ☐ Emphysema ☐ Heart Disease ☐ High Blood Pressure ☐ Neurological ☐ Stroke
Review of Systems
(Check all that apply)
SIGNATURE
I certify that the above information is correct to the best of my knowledge. I understand that I am responsible for notifying the physician or medical staff of any updates.
Patient Signature: ____________________________________ Date: ____ / ____ / ______
TREATMENT CONSENT
I consent and give permission to Dr. Amy Hall, D.P.M. (and her assistants or designated replacement) to administer and perform any procedures she deems necessary.
Signature of Patient, Parent, Guardian, or Personal Representative: _______________________ Date: _______________________ Printed Name: _________________________________________ Relationship to Patient: _________________________________
INSURANCE ASSIGNMENT AND RELEASE
I certify that I have insurance coverage with: Insurance Company/Companies: ______________________________________
I assign directly to Dr. Amy Hall, D.P.M. any insurance benefits otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.
Dr. Hall may use and disclose my health information to the above‑named insurance company(ies) and their agents for payment and benefit determination. This consent expires when my current treatment plan is completed or one year from the date signed.
MEDICARE / MEDIGAP AUTHORIZATION
I request that payment of authorized Medicare benefits and, if applicable, Medigap benefits be made to me or on my behalf to:
Dr. Amy Hall, D.P.M.
for any services furnished to me by that provider.
I authorize any holder of medical information about me to release information to the Centers for Medicare and Medicaid Services, my Medigap insurer, and their agents as needed to determine benefits.
Signature: __________________________________________ Printed Name: _______________________________________ Date: ____________________ Relationship: ____________________
HIPAA CONSENT TO RELEASE OF MEDICAL RECORDS
Bucks Foot & Ankle Care 638 Newtown Yardley Rd | Commons West Suite 1‑H | Newtown, PA 18940 Amy Hall, D.P.M. Ph: 215‑321‑1200 Fax: 215‑321‑6100
I authorize Bucks Foot & Ankle Care, its physicians, agents, and affiliated providers to use and/or disclose my personal health information, including medical records, progress notes, discharge summaries, operative notes, lab results, radiology reports, and consultations, for purposes of treatment, continuity of care, billing, payment, and approved administrative or educational uses.
Information may be released to my insurance company, managed care organizations, government programs, my family physician, other providers involved in my care, family members or friends involved in my care, and any additional individuals listed below:
Others: __________________________________ Address: _________________________________
I understand that certain sensitive information (drug/alcohol treatment, mental health, HIV/AIDS) requires a separate consent form. I release Bucks Foot & Ankle Care and its representatives from liability for disclosures made in accordance with this authorization. I acknowledge receipt of the Bucks Foot & Ankle Care Privacy Practices.
Signature: ________________________________ Date: ________________________________
PATIENT FINANCIAL RESPONSIBILITY STATEMENT
Thank you for choosing Bucks Foot & Ankle Care. By receiving medical services, you accept financial responsibility for all charges incurred.
You are responsible for deductibles, co‑payments, co‑insurance, and any amount not covered by your insurance. Our office will submit claims to your insurance carrier(s), but you must provide complete insurance information at the time of your visit.
Bucks Foot & Ankle Care requests a credit card to keep on file through Practice Fusion Payment Systems. All information is kept confidential and secure.
After your insurance processes the claim, any remaining balance will be billed to the address you provide. If payment is not received within 30 days, the credit card on file will be charged for the outstanding balance.
Patient Signature: ________________________________ Printed Name: _____________________________________ Date: _______________________________