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New Patient Form

Is this your first time visiting us? Take a few minutes and fill out the information below so we can make your visit with us a breeze!

New Patient Form

Step 1 of 9

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What Is Your Reason For Visiting Us?
Patient Information
Name
First Middle Last
Date of Birth
Month
Day
Year
Cell Phone
Home Phone
Patient or Guarantor Email Address
Would you like access to the patient portal?
- Yes
- No
Address
Street Address Address Line 2 City State ZIP Code
May we contact you via email for appointment reminders?
- Yes
- No
May we contact you via text message for appointment reminders?
- Yes
- No
Sex
- Male
- Female
Marital Status
- Married
- Divorced
- Widowed
- Single
Race
- American Indian or Alaska Native
- Asian
- Black or African American
- Native Hawaiian or other Pacific Islander
- White or Caucasian
- Other
Ethnicity
- Hispanic or Latino
- Non-Hispanic or Latino
Language

Patient Employer Information
Employer Name
Employer Phone
Employer Email
Employer Address
Street Address Address Line 2 City State ZIP Code

Insurance Policy Holder Information
Insurance Policy Holder-the person who carries the insurance
- Same as Patient
- Different than Patient
Insurance Plan Name
ID Number
Insurance Plan Name (#2)

If Applicable
ID Number (#2)

If Applicable
Name
First Middle Last
Date of Birth
Month
Day
Year
Relationship to Patient
Phone
Address
Street Address Address Line 2 City State ZIP Code
Employer Name
Employer Phone
Employer Email

Emergency Contact
Name
First Last
Relationship to Patient
Cell Phone
Home Phone

Pharmacy Information
Pharmacy Name
Phone
Address
Street Address Address Line 2 City State ZIP Code

Personal Medical History
Check All That Apply To You*
- NO KNOWN ACTIVE MEDICAL PROBLEMS
- Anemia/Blood Disorder
- Anxiety/Depression
- Arthritis
- Asthma
- Blood Clots
- Cancer
- Depression
- Diabetes
- Epilepsy/Seizures
- Frequent Headache/Migraines
- Gout
- Heart Trouble
- High Blood Pressure
- High Cholesterol
- Kidney Disease
- Mental Health Disorder
- Skin/Connective Tissue Disorder
- Stomach/Ulcer Disorder
- Stroke
- Thyroid Disease
- Tuberculosis
- Other (specify):
Please list any other medical conditions not listed above:*
Height
Weight
Shoe Size
Occupation
Family Physician
Physician Phone
Last Seen
MM slash DD slash YYYY
Has any family member had any of the following?
- NO KNOWN FAMILY HISTORY OF THESE CONDITIONS
- Cancer
- Heart Trouble
- Kidney Disease
- Tuberculosis
- Asthma
- Blood Clots
- Diabetes
- High Blood Pressure
- Stroke
- Arthritis
What is your relationship to the family members with the medical conditions you selected above?
List the medical condition with the relationship
Mother
- Living
- Deceased
Cause of Mothers Death
Father
- Living
- Deceased
Cause of Fathers Death
Do you smoke Currently
- Yes
- No
How Many Packs/day?
For How Long?
Have you smoked previously?
- Yes
- No
When did you quit?
Do you drink alcohol currently?
- Yes
- No
How many days/week?

Allergies
What Allergies Do You Have?*
- Food Allergies
- Medication Allergies
- Environmental Allergies
- No Known Allergies
What are your food allergies?
What are your medication allergies?
What are your environmental allergies?

Current Medications
Are you currently taking any medications?*
- Yes
- No
Please list all medications

Surgical History
Have you had any previous surgeries?*
- Yes
- No
Please list all surgical procedures
Please also include the approximate date and year
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CONTACT US

Phone: 317.284.8888
Fax: 317.284.8891

Make An Appointment

New Patient Form

ADDRESS

Hamilton Foot And Ankle Care LLC
Thomas A. Vogel, D.P.M.
9865 East 116th Street #300
Fishers, IN 46037

Business Hours

Monday: 9:00 AM - 5:00 PM
Tuesday: 8:00 AM - 5:00 PM
Wednesday: 7:00 AM - 4:00 PM
Thursday: 7:00 AM - 4:00 PM
Friday: Closed For Surgery
Saturday/Sunday: Closed

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