Lansdowne, PA
(610) 626-3338

REQUEST APPOINTMENT

Intake Form

Please complete the following form and answer all questions before arriving for your appointment.

All fields marked with an asterisk (*) are required.

Be sure to include your insurance information.
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Patient Information

First name (*)

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Middle Initial

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Last name (*)

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Your Email Address (Responsible Party) (*)

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Mailing Address (*)

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City (*)

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State (*)

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Zip-Code (*)

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Phone number (*)

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Age (*)

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Date of Birth: Month (*)

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Day (*)

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Year (*)

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Sex (*)

Male Female

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Marital Status (*)

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Height (*)

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Weight (*)

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Shoe Size (Length and Width) (*)

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Race(*)

*This information is requested due to Healthcare Reform laws dictated by Congress.

Ethnicity

Hispanic or Latino Non-Hispanic or Non-Latino Decline to Specify

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Preferred Language(*)

English Spanish Other

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Specify

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Are you pregnant?(*)

No Yes

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Are you nursing?(*)

No Yes

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Have you completed an Advance Directive (living will)? (*)

Yes No

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Primary Care Physician (*)

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Primary Care Physician Address (*)

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Physician Phone Number (*)

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Date last seen: Month

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Day

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Year

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Pharmacy (*)

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Pharmacy Phone (*)

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Whom may we thank for referring you? (*)

Who?

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Other

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Primary Reason for Visit (*)

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Duration of Condition (*)

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What helps / makes it worse?

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Is it limiting your activity level? (*)

Yes No

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Secondary concerns (if there are any)

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Please list any drug allergies (*)

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List Medications You Take (*)

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Specify other

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If you have cancer, please list type and treatment

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Please list past surgeries and year surgery was performed (*)

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Is your problem related to a Workman’s Comp injury or an auto/other accident?(*)

No Yes

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Do you drink alcohol?(*)

Never Past Yes

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If you answered yes above, do you abuse alcohol?

Yes No

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How often?

Daily 1-2 x Week 1-2 x Month 1-2 x Year

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Do you smoke, vape or use chewing tobacco?(*)

Never Past Yes

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If you answered "past" above, when did you stop?

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Please specify

Cigarettes Cigars Chewing Tobacco Vaping

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How many per day?

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Method of Quitting

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Do you have/have had a substance abuse problem?(*)

Never Past Yes

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If you answered "past" above, when did you stop?

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Please specify

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Do you participate in a regular physical fitness program?

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Please Specify

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Family History

Which family members had the below medical conditions? (father, mother, sibling, etc.)

Any Family Members With Diabetes?

Yes No

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Diabetes

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Any Family Members That Had Stroke?

Yes No

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Stroke

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Any Family Members With Cancer?

Yes No

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Cancer

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Any Family Members With Arthritis?

Yes No

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Arthritis

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Any Family Members That Had Heart Attack?

Yes No

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Heart Attack

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Any Family Members With HTN?

Yes No

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HTN

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Is There Any Other Medical Condition in Your Family?

Yes No

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Other

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Insurance Information

Subscriber's Name (*)

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Subscriber's D.O.B.

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Patient's Relation to the Subscriber (*)

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If a Patient Has a Different Address Than Subscriber Please State the Patients Address

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HMO (*)

Yes No

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Primary Insurance (*)

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Policy Number (*)

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Policy Holder Name (*)

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Policy Holder Date of Birth: Month (*)

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Day (*)

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Year (*)

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Secondary Insurance

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Secondary Policy Number

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Occupation (*)

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Employer (*)

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Employer Address

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City

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State

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Zip-Code

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Employer Phone Number

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Emergency Contact

First Name (*)

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Last Name (*)

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Relationship to Patient (*)

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Phone (*)

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Responsible Party (if minor patient)

First Name

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Last Name

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Relationship to Patient

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Date of Birth: Month

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Day

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Year

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View Privacy Policy

All office visit charges and co-pays are due at the time services are rendered. It is the patient who is responsible for any and all financial aspects of services rendered. There will be a charge for returned checks. I agree to pay for all deductibles, co-pays, non-covered services and any portion of covered services not paid in full by my insurance plan and understand that such payments are due at the time of service or immediately upon presentation of the bill. I hereby authorize payment of medical benefits to George L. Yarnell, DPM, who will accept the assignment of medical benefits. I instruct my health care benefits plan administrator, i.e. PLAN to pay George L Yarnell, D.P.M directly for all professional and medical services provided by George L Yarnell, D.P.M. through the means of electronic funds transfer(s) (EFT) or by check(s) made payable to and mailed to George L Yarnell, D.P.M.. I AUTHORIZE THE RELEASE OF ANY MEDICAL INFORMATION NECESSARY TO PROCESS CLAIMS.

I Agree (*)

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The above information is correct to the best of my knowledge. I understand that throughout my treatment, I am responsible for notifying the physician and/or medical staff of any and all updates to the information listed above. I also give permission for photographs of my feet to be taken that are to be kept as part of my medical record only. They will not be published as part of medical research or disbursed in any way without my permission.

I Agree (*)

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I acknowledge that I was provided a copy of the Notice of Privacy Practices for George L Yarnell, D.P.M. and I have read (or had the opportunity to read if I so choose) and understood the Notice.

PAYMENT RESPONSIBILITIES

We are pleased to welcome you to our office. New Patients are always appreciated. Our practice has grown as a result of its excellent relationship with our referring doctors and patients. As our patient, please feel free, at any time, to express any concerns or to ask any questions that you may have for the doctor or our staff. In order to assist you in making payment(s) for your podiatric treatment, the following options are listed. Please read them carefully and feel free to discuss them with us.

If you DO NOT have insurance: Payment is due, in full, at the time treatment is provided. Payment arrangements can be made.

*For your convenience, we accept all major credit/debit cards and cash.

If you have Insurance: The percentage of coverage by your insurance company may be based on your insurance company’s own reduced fee schedule for medical services and may be less than actual charges resulting in lower coverage for you. The office of George L. Yarnell, D.P.M. has no control over this situation. Lower payment is a direct result of the plan selected by you or your employer. Please be advised that we cannot waive co-payment. We are required by law to collect co-payment and deductibles.

Commercial Insurance: We will submit your claim to your insurance carrier for you. You are responsible for any deductible or co-payment not covered by your insurance. Once our office has received payment from the insurance company, you will be billed, with 30 day terms, for any amount still owed. You may choose to keep a credit card on file for those balances left to you by your insurance company.

Medicare: This office accepts Medicare assignment. Medicare patients are fully responsible, however, for the initial yearly deductible and the 20% co-insurance. Federal law requires that physicians collect this amount. If you have a secondary insurance to cover the 20%, we will submit the balance to that insurance for payment and you will only be responsible for the yearly deductible.

Please sign with your initials (*)

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Please ensure you have completed all mandatory fields on this form (indicated with an (*) asterisk next to the field) and please wait until our thank you page loads to ensure the form was successfully submitted otherwise your data will be lost.

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Intake Form

Patient Information

Social History

Family History

Insurance Information

Emergency Contact

Responsible Party (if minor patient)

Consent for Treatment and Acknowledgement of Policies

PAYMENT RESPONSIBILITIES