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New Patient Intake

Save time at your first visit by completing your intake paperwork online. All information is kept strictly confidential and reviewed only by Dr. Johnson and our clinical staff. If you'd prefer, you can download the PDF version to print and bring with you.

Patient Information
Sex
Preferred Phone *
Insurance

Primary Insurance

Is a referral required?

Patient is responsible for obtaining referrals.

Secondary Insurance (if applicable)

Today's Problem
Rate the pain (0 = no pain, 10 = worst pain)
Location of today's problem(s) — check all that apply

Left Foot

Right Foot

Allergies & Medications

List each medication on its own line with dose and frequency. If you have many, feel free to bring a printed list to your visit.

Medical History

Please check any conditions you have personally experienced.

Cardiovascular

Respiratory

Gastrointestinal

Liver / Gall Bladder

Dermatology

Kidney

Endocrine

Nervous / Psychiatric

Genitourinary

Rheumatology

Hematologic

Immune

Musculoskeletal

Are you pregnant?
Are you nursing?
Surgical History

Please list all surgeries you have had.

Surgery Year
Family History

Check any known health conditions in your family.

Social History
Tobacco Use
Alcohol Use
Drug Use
Marital Status
Acknowledgements & Consent

Medical Information Release

I acknowledge that I have been offered a copy of the NOTICE OF PRIVACY POLICY of Treasure Valley Foot and Ankle ("TVFA") and that TVFA may release all or portions of my medical record to me, and to people or companies responsible to pay the charges for my care, such as my insurance or health benefits companies, or worker's compensation carriers. I further acknowledge that TVFA may disclose my patient information to referring or treating health care providers, and for payment and health care operations. I hereby authorize TVFA to obtain my medical information from other health care entities and providers, including but not limited to, copies of lab results, diagnostic test reports, film/images, and other clinic information deemed necessary by TVFA physicians or representatives. I understand that I may inspect my protected health information, request more information, and revoke this authorization, as permitted by the federal privacy regulations and in accordance with TVFA's privacy policy.

Consent for Treatment

I hereby consent to the medical treatment, diagnostic, and laboratory tests, and other procedures, which the physician(s) may deem advisable in treatment of my case (or as legal guardian for patient). TVFA will determine the proper disposition of any tissues, parts, or body fluids consistent with state and federal laws. This agreement will remain in effect until I choose to revoke it in writing.

Financial Responsibility and Agreement

I hereby authorize any benefits due me to be paid directly to Treasure Valley Foot and Ankle. I understand and agree that I am financially responsible for all deductible amounts, co-insurance, co-pay or non-covered services or services deemed as "non-medically necessary" by my third party insurance carrier which could include orthotics, braces, splints, over-the-counter medications, heel cups, pads, toe separators, etc. I agree that I am responsible for satisfying any conditions necessary for insurance or health benefits, including obtaining a valid referral from my primary care physician, if necessary. All delinquent accounts will be charged an interest rate of 1.5% per month, 18% per annum. In the event any balance is not paid as agreed, I agree to pay a collection fee and all costs of collection. In the event of a lawsuit to collect the unpaid balance, I further agree to pay court costs and reasonable attorney fees. I agree to permit TVFA to service my account or to collect any amounts I may owe, and to contact me by telephone at any telephone number associated with my account, including wireless telephone numbers, which could result in charges to me. TVFA may also contact me by sending text messages or e-mails, using any email address I provide to them. Methods of contact may include using pre-recorded/artificial voice messages and/or use of an automated dialing device, as applicable. In consideration for medical services rendered, I acknowledge that I have access to TVFA's financial policy and agree to pay for said medical services according to such terms. To the best of my knowledge, I have answered the questions on this form accurately. I understand that providing incorrect information can be dangerous to my health. I understand that it is my responsibility to inform the doctor and office staff of any changes in my medical status.

Typing your name here serves as your electronic signature.

* Required fields. Your information is kept confidential. If you have trouble submitting, please call us at (208) 272-9253.