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PERSONAL INFOPalm Beach Foot and Ankle - Patient RegistrationPATIENT NAMEDOB:Local Mailing AddressSSN:City/State/Zip CodeHome Phone #Alternate AddressCell Phone #City/State/Zip CodeSexEmployerRetired? Y NOccupationDo you have a living will?Emergency Contact (other than spouse)/Relationship:Appt Date/Time Male FemaleMarital StatusS M D WSpouse's NameSpouse's Phone Y NEmail Address Asian White/Caucasian Black/African American OtherPhone # Hispanic/LatinoPreferred Language Native American/Alaska NativePCP/PHARMACY Native Hawaiian/Other Pacific IslanderPRIMARY PHYSICIANAddressPhone NumberDate Last SeenFax NumberPHARMACY NAMEAddressPhone NumberFax NumberSIGNATUREINSURANCE INFORMATIONPalm Beach Foot and Ankle participates with Medicare and many other insurance networks. It is ultimately the patient's responsibility to ensure networkparticipation with the insurance company. PBFA cannot assume responsibility for network participation. Please provide a photo ID and insurance cardsto receptionist.PRIMARY INSURANCE:Policy Holder (if other than patient)Policy NumberRelationship to PatientGroup NumberDate of BirthSECONDARY INSURANCE:Policy Holder (if other than patient)Policy NumberRelationship to PatientGroup NumberDate of BirthI hereby authorize the release of any medical information pertaining to my treatment or information necessary for processing insurance claims andpayment of the medical benefits to myself or the party who accepts assignments. This authorization will remain valid until revoked by me in writing. Iunderstand that I am legally responsible for all charges whether or not reimbursed by my insurance company. I understand and accept that if I fail to paymy bill or any monies due and owing Palm Beach Foot and Ankle by the scheduled due date, and fail to make acceptable payment arrangements to bringmy account current, PBFA may refer my delinquent account to a collection agency. I further understand that if PBFA refers my account balance to a thirdparty for collection, a collection fee will be assessed and will be due in full at the time of the referral to the third party. The collection fee will becalculated at the maximum amount permitted by applicable law but not to exceed 30% of the amount outstanding. For purposes of this provision, thethird party may be a debt collection company or an attorney. If a lawsuit is filed to recover an outstanding balance, I shall be also responsible for anycosts associated with the lawsuit such as court costs or other applicable costs. Finally, I understand that my delinquent account may be reported to oneor more of the national credit bureaus.SIGNATUREDATERELATIONSHIP (if other than patient)REASON (if unable to sign)

Palm Beach Foot and AnkleACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICESI acknowledge that I was provided a copy of the Notice of Privacy Practices (posted in the reception room) and that Ihave read them or declined the opportunity to read them. I understand the Notice of Privacy Practices discloses how wemay use and disclose my medical information.I understand that this authorization is voluntary and if disclosed, it will expire one year from the date of execution if noauthorization date is given below. I acknowledge and agree that the practice may disclose my protected healthinformation and information contained in my medical record to the following: Spouse: Legal Representative: Other: Authorization Expiration Date:Patient SignatureDateMEDICARE SIGNATURE ON FILEI request that payment of authorized Medicare benefits be made either to me or on my behalf of Palm Beach Foot andAnkle for any services furnished me by the listed provider/supplier. I authorize any holder of medical information aboutme to release to the Health Care Financing Administration and its agents any information needed to determine thesebenefits or benefits payable to related services. I understand that my signature requests that payment be made andauthorizes release of medical information necessary to pay the claim. If "other health insurance" is indicated in item 9 ofthe HCFA-1500 form, or elsewhere on other approved claim forms or electronically submitted claims, my signatureauthorizes releasing of the information to the insurer or agency shown. In Medicare assigned cases, theprovider/supplier agrees to accept the charge determination of the Medicare carrier as the full charge, and the patient isresponsible only for the deductible, coinsurance, and non-covered services. Coinsurance and the deductible are basedupon the charge determination of the Medicare carrier.Provider: Palm Beach Foot and AnklePatient Name (please print)Medicare NumberPatient SignatureDateWHOM MAY WE THANK FOR SENDING YOU TO OUR OFFICE? DoctorPatientNewspaperOther Verizon Yellow PagesThe Yellow BookInsurance Provider ListPassed by LocationWORKER'S COMPENSATION / ACCIDENT INFORMATIONIs your treatment today due to a work related injury?What is the date of your injury?Do you have written authorization from your employer and comp carrier to be treated? Yes No Yes NoIs your treatment today a result of a motor vehicle accident?What is the date of your injury? Yes NoIs your treatment today a result of an accident / liability case?What is the date of your injury? Yes NoPatient SignatureDate

History & Medical HistoryMEDICAL HISTORYTODAY'S VISITIt's important that we learn your history!EXPLAIN YOUR FOOT/ANKLE PROBLEM RIGHT LEFTDescribe the pain/discomfort: Numbness Burning OtherWhen did the pain/discomfort begin?What makes the pain/discomfort better?What makes the pain/discomfort worse?ALLERGIES:List all drug, food and environmental allergies and describe reaction: Penicillin Aspirin Anesthesia Shellfish Nickel/Metal Radiographic Contrast Dye Other NONE Narcotic Agent/Codeine Sulfa DrugsMEDICATION: Please list all medications, herbal supplements, and vitamins.If Medication list is attached, please check here. MEDICATIONHOW OFTEN NONEMEDICATIONHOW OFTENSURGERY: Please list all major surgery and date performed.PROCEDUREDATEFAMILY HISTORY (please check & list A ARTHRITIS ASTHMA BLEEDING DISORDERS CANCER CIRCULATION PROBLEMS DIABETIC (how long?) DIABETES AVG GLUCOSE EPILEPSY FOOT PROBLEM(S) GOUT HEART DISEASE HEPATITIS HIGH BLOOD PRESSURE HIGH CHOLESTEROL HIV/AIDS INJURY/TRAMA MAJOR DO YOU?YYYYSOCIALSOCIAL HISTORYDrink alcohol?Smoke tobacco?Have a history of drug abuse?Caffeine Use?MISCFAMILY SharpMISCELLANEOUSDO YOU?Exercise?Are you pregnant?YYPatient SignatureNNNNNN NONEPROCEDURECONDITIONKIDNEY DISEASELIVER DISEASEMENTAL ILLNESSMITRAL VALVE PROLAPSEMULTIPLE SCLEROSISNAIL DISORDERSNERVE DISORDERSOBESITYPHLEBITISPULMONARY DISEASEPNEUMATIC FEVERSTDSKIN PROBLEMSSTOMACH/INTEST PROBLEMSSTROKETHYROID DISEASEVARICOSE VEINSHow often?How often?ExplainExplainHeight:Weight:Shoe Size:DateDATESELF FAMILY/Relationship

REVIEW OF SYSTEMS:Please check any of the following that you are currently experiencing or have recently experienced.CONSTITUTIONAL Fever Chills Sweats Weight ChangeHEAD / EYES / EARS / NOSE / THROAT Wear Contact Lens Double Vision Difficult Swallowing Nosebleeds Wear Eyeglasses Cataract Neck Pain Eyesight Problems Dentures Dizziness Sore Throat Ringing in EarsCARDIOVASCULAR Chest Pain / Discomfort Swelling Lower Extremity Cardiovascular Symptoms Leg Pain with Exercise Heart Murmur PalpitationsHEMATOLOGIC / LYMPHATIC Bleeding Problem Anemia Swollen Glands Skin Lump / Location LymphomaRESPIRATORY Difficulty Breathing Exposure to TB Wheezing Coughing Previous Pulmonary Disease Pulmonary SymptomsGASTROINTESTINAL Nausea Decrease in Appetite Vomiting Abdominal Pain Diarrhea ConstipationENDOCRINE Often Thirsty Urinary Symptoms Frequent Urination Prostate Problems Thyroid Disease Prior Kidney DiseaseMUSCULOSKELETAL Musculoskeletal Symptoms Weakness of Limbs Feeling Weak Prior Fracture Joint Pain, ArthralgiaNERVOUS SYSTEM Ataxia Neuropathy Speech Difficulties Confusion / Disorientation Headache Fainting ConvulsionsSKIN Rash Color Change Eczema (Pruritus) Ulcer Slow Healing Growth Lesions Infections Hair Loss Sun Sensitivity CrackingALLERGIC / IMMUNOLOGIC HISTORY Dermatitis Rheumatoid Arthritis Lupus Collagen VascularPSYCHIATRIC Nervousness Tension DepressionPatient SignatureDate

Palm Beach Foot and AnkleDr. Alan Hartstein Dr. Hisham Ashry Dr. Jonathan MoskovitsDr. Xavier Sanchez Dr. Jeffrey Rockefeller Dr. Kali Etheredge Dr. Kristin SilinskiWELCOME INFORMATIONWe would like to take this opportunity to welcome you to our office. We hope that your visit will be pleasant. If our staff can do anythingto make you feel more comfortable, please don’t hesitate to ask. Please read the following information regarding our office policies andyour financial responsibility. Please understand that your insurance is a contract between YOU and your INSURANCE COMPANY. Weare not a party to that contract. You will be responsible for any deductible and/or copayment at the time of service. Payment for allservices is due at the time that services are rendered unless payment arrangements have been approved in advance by our staff. Weaccept cash, checks, MasterCard, Visa, and American Express.We may accept assignments of insurance benefits in certain circumstances. You will be responsible for balances NOT covered or paidby your insurance company. If payment is not received within 90 days from the date of service, you will be responsible for the balanceon your account. You will receive separate bills from outside laboratories or Pathologists if any lab work is performed as we do NOThandle the billing for lab work done outside our office. We will gladly discuss your proposed treatment and answer any questions relatingto your insurance.CONSENT FOR EVALUATION & TREATMENTTo the Patient: You have the right, as a patient, to be informed about your condition and the recommended surgical, medical, or diagnosticprocedure to be used so that you may make the decision whether or not to undergo any suggested treatment or procedure after knowingthe risks and hazards involved. At this point in your care, no specific treatment plan has been recommended. This consent form is simplyan effort to obtain your permission to perform the evaluation necessary to identify the appropriate treatment and/or any identifiedcondition(s).This consent provides us with your permission to perform reasonable and necessary medical examinations, testing and/or treatment. Bysigning below, you are indicating that (1) you intend that this consent is continuing in nature even after a specific diagnosis has beenmade and treatment recommended; and (2) you consent to treatment at this office or any other satellite office under common ownership.The consent will remain fully effective until it is revoked in writing. You have the right at any time to discontinue services. You have theright to discuss the treatment plan with your physician about the purpose, potential risks and benefits of any test ordered for you. If youhave any concerns regarding any test/treatment recommended by your health care provider, we encourage you to ask questions.I voluntarily request a physician, and/or other health care provider or the designees as deemed necessary, to perform reasonable andnecessary medical examination, testing, and treatment for the condition which has brought me to seek care at this practice. I understandthat if additional testing, invasive or interventional procedures are recommended, I will be asked to read and sign additional consentforms prior to the test(s) or procedure(s).I have read and understand the financial policy of this office as it applies to me and will abide by it. I also certify that I have read and fullyunderstand the above statements and consent fully and voluntarily to its contents.SIGNATURE OF PATIENT OR PATIENT REPRESENTATIVEDATESIGNATURE OF WITNESSDATE

Fever Chills Sweats Weight Change HEAD / EYES / EARS / NOSE / THROAT Wear Contact Lens Nosebleeds Neck Pain Dizziness Double Vision Wear Eyeglasses Eyesight Problems Sore Throat Difficult Swallowing Cataract Dentures Ringing in Ears CARDIOVASCULAR Chest Pain / Discomfort Cardiovascular Symptoms Heart Murmur Swelling Lower Extremity Leg Pain with Exercise Palpitations