complete medical and surgical footcare
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ALL PODIATRY GROUP PATIENT FORMS

 
Listed below are several forms that may need to be completed prior to your first visit with All Podiatry Group. For your convenience you can print out these forms and bring the completed forms with you on the day of your appointment. All forms should be completed accurately using black ink. Please contact us if you have any questions or concerns about the information that needs to be provided.
 
 
     Patient Information Sheet  
 
  When completing this form please remember, if the patient is 18 years or older, regardless of whose name the insurance policy is held, the patient is considered the "Responsible Party".  
 
 
     Health History and Information Sheet  
 
  Please take time to be as detailed as possible with this form. Be sure to list any and all medications you are taking. If need be, you may use a separate piece of paper to list them all.  
 
 
     Consent Form  
 
  By signing our consent form the patient authorizes examination and treatment by Dr. Baker and Dr. Zuri. The consent form also allows us to bill the appropriate insurance.  
 
 
     Waiver of Non-Covered Services  
 
  Please read this form carefully. Some services and products may not be covered by your insurance policy. We will inform the patient of any uncovered service or product, and payment will be the responsibility of the patient or responsible party. Your signature is an acknowledgement and agreement for payment.  
 
 
     Privacy Practices  
 
  This form acknowledges that the patient understands that we will not give their information to a third party unless we have permission to do so.  
 
 
     Cancellation Policy  
 
  All Podiatry Group requires a 24 hour cancellation notice prior to your scheduled appointment. Please contact us via telephone if you need to cancel your appointment.  
 
 
 
  If your computer is not equipped with Adobe Acrobat Reader you can download the free software from the Adobe website.
 
 
CONTACT | Tampa: 813.879.7850 | Brandon: 813.681.3558
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