Skip Navigation
Skip Main Content

New Patient Registration Form: Minor

Please select an office.

Demographics

Demographics

Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Gender:
Please select an option.
Please complete this field.
Please complete this field.
Preferred method of contact?
Please select an option.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.

Emergency Contact Information

Emergency Contact Information

IN CASE OF EMERGENCY, who will be notified?
Please complete this field.
Please complete this field.
Please complete this field.
How did you hear about Northern Illinois Foot & Ankle Specialists?
Please select an option.

Insurance & Pharmacy Information

Insurance & Pharmacy Information

PLEASE CONTACT YOUR INSURANCE COMPANY PRIOR TO YOUR APPOINTMENT TO VERIFY YOUR BENEFITS
Will you be using insurance?
Please select an option.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.

Patient History

Patient History

Please complete this field.
Please complete this field.
Please complete this field.
Preferred Language
Please select an option.
Ethnicity - Hispanic or Latino?
Please select an option.
Race
Please select an option.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please select an option.
Please select an option.
Please complete this field.
Please complete this field.
Smoking/Drinking History
Do you smoke?
Please select an option.
Do you drink alcohol?
Please select an option.
Please complete this field.
ALLERGIES: MEDICATION/ENVIRONMENTAL
Activity Level
Please select an option.

Past Medical History

Past Medical History

If female, is there a chance you are pregnant?
Please select an option.
Please complete this field.

Family History of Medical Problems

Family History of Medical Problems

Please sign your name in the area below

By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

E-signature image