Patient Intake Form

top of page

Home
Patient Care
- Patient Intake Form
Insurance
Staff
ADK Rock Climbing Foot
Contact & Locations
- News
More

Use tab to navigate through the menu items.

New Patient Intake Form

patient information

First Name

Nickname

Email

Last Name

Date of Birth

Male/Female

Home Address

Home City, State, ZIP

Mailing/Alt. Address

Mailing City, State, ZIP

Primary Phone

Alternate Phone

emergency contact/responsible party

Emergency Contact/Caregiver Name

Primary Phone

Relationship to Patient

Alternate Phone

Reason for your visit/medical history

Referring Physician

Primary Care Physician

Medical Condition/Injury

Select an option *

Right

Left

Bilateral

Spinal

Shoe Size

Height

Weight

Allergies

If you have Diabetes, have you had a sore or ulcer with difficulty healing?

Yes

No

If so, where?

Do you have areas of poor sensation?

Yes

No

If so, where?

Have you received a brace/support for the same injury within the past 5 years?

Yes

No

Please indicate if you have, or have history of, any of the following conditions:

Arthritis

Leg length discrepancy

Stroke

Artificial joints

Diabetes

Neuropathy

Kidney trouble

Osteoporosis

Scoliosis

Cancer

Spina Bifida

Developmentally delayed

insurance information

Are you a veteran? *

Yes

No

Is your insurance a Medicare or Medicaid replacement plan? *

Yes

No

Primary Insurance Company

Subscriber Name (if someone other than patient)

Subscriber DOB (if someone other than patient)

Secondary Insurance Company

Secondary Subscriber Name (if someone other than patient)

Secondary Subscriber DOB (if someone other than patient)

worker's comp/no fault/school injuries

Workplace where injury occurred (company, city)

Select a date

Insurance

Supervisor/HR Contact/School Nurse

Social Security:

Case #

Caseworker

Thanks for submitting!

Contact

Lake Placid:

7 Old Military Road

Lake Placid, NY 12946

Tel: 518-523-2419

Fax: 518-523-7192

Plattsburgh:

106 West Bay Plaza

N. Margaret Street

Plattsburgh, NY 12901

Tel: 518-324-6569

Fax: 518-324-6570

Malone:

70 Constable St

Malone, NY 12953

Tel: 518-521-3257

info@mountainoandp.com

Enter Your Name

Enter Your Email

Enter Your Subject

Message