CALL (360) 977-
IN ORDER TO REDUCE YOUR WAIT TIME, OUR PATIENT FORMS ARE AVAILABLE FOR YOU TO DOWNLOAD, REVIEW AND COMPLETE PRIOR TO YOUR APPOINTMENT. WE LOOK FORWARD TO YOUR VISIT.
STEP 1: LOCATE THE CORRECT PDF FORM(S), CLICK ON THE LINK AND PRINT THEM.
STEP 2: COMPLETE AND SIGN EACH FORM WHERE INDICATED.
STEP 3: ONCE YOUR FORMS ARE COMPLETE:
BRING THEM WITH YOU TO YOUR APPOINTMENT
FAX THEM TO THE OFFICE AT (888) 568-
MAIL (AT LEAST ONE WEEK PRIOR TO YOUR APPOINTMENT) TO:
ANKLE AND FOOT PHYSICIANS AND SURGEONS, PLLC
406 SE 131ST AVE
SUITE 109
VANCOUVER, WA 98683
NOTE: WE CARE ABOUT THE PRIVACY OF YOUR PERSONAL HEALTH DATA AND PERSONALLY IDENTIFIABLE INFORMATION. THEREFORE, WE DO NOT ALLOW FOR ONLINE SUBMISSION OF ANY PATIENT FORMS.
NEW PATIENT REGISTRATION PACKET
PLEASE COMPLETE AND RETURN ALL PAGES CONTAINED WITHIN THIS PACKET OF INFORMATION. NOTE: IF THE PATIENT IS AN ATHLETE PLEASE COMPLETE THE ATHLETE DATA FORM BELOW.
NEW PATIENT REGISTRATION PACKET (MINORS)
THIS PACKET IS SPECIFIC TO THOSE PATIENT WHO ARE UNDER THE AGE OF 18. THIS MUST BE
COMPLETED BY A PARENT AND ADDITIONALLY, WE REQUEST THAT THE NON-
ADDITIONAL FORMS
FOR ATHLETES BEYOND RECREATIONAL PLAY COMPLETE THIS FORM TO ASSIST US IN CARING FOR SPORT SPECIFIC INJURIES AND AID IN RETURN TO SPORT.
COMMUNICATION PREFERENCES CHANGE
USE THIS FORM TO CHANGE HOW AND WITH WHOM WE CAN COMMUNICATE APPOINTMENT REMINDERS, TEST RESULTS, ETC WHEN YOU ARE UNAVAILABLE.
CONTACT/PERSONAL INFORMATION CHANGE
PLEASE SUBMIT THIS FORM IF YOU HAVE HAD ANY CHANGE TO YOUR PHONE
NUMBER (S), ADDRESS, OR PERSONAL INFORMATION SINCE YOU PREVIOUS VISIT.
HEALTH HISTORY AND DATA CHANGE
IF YOU HAVE BEEN DIAGNOSED WITH A NEW CONDITION, THE STATUS OF A CONDITION HAS CHANGED, OR YOU HAVE NEW/DISCONTINUED MEDICATIONS, PLEASE COMPLETE THIS FORM.
HIPAA PRIVACY STATEMENT (COMPLETE VERSION) SUMMARIZED VERSION
INCLUDED IN THE NEW PATIENT REGISTRATION PACKETS AND FOR YOUR REFERENCE.
HIPAA PRIVACY STATEMENT RECEIPT ACKNOWLEDGEMENT
THIS ACKNOWLEDGEMENT FORM MUST BE SIGNED AFTER REVIEW OF THE HIPAA PRIVACY STATEMENT AND IS UPDATED ON AN ANNUAL BASIS.
INSURANCE CHANGE
COMPLETE THIS FORM IF YOU HAVE CHANGED INSURANCE OR ADDED/CHANGED A SECONDARY CARRIER.
RELEASE OF MEDICAL RECORDS (THIS FORM CAN NOT BE FAXED)
IF YOU NEED COPIES OF YOUR MEDICAL RECORDS, COMPLETE THIS FORM AND EITHER MAIL IT
TO THE OFFICE ADDRESS ABOVE (WE RECOMMEND A METHOD WITH DELIVERY CONFIRMATION) OR
DROP IT OFF AT THE OFFICE. WE ARE UNABLE TO ACCEPT NON-
NON-
COMPLETE THIS FORM TO ADD/REMOVE AN AUTHORIZED CARE GIVER FOR A MINOR PATIENT.