- Dr. Stephen R. Pittman, D.P.M. - https://www.drstephenpittman.com -

Registration

American Board of Podiatric Surgery

Fellow, American College of Foot Surgeons

Stephen R. Pittman, D.P.M., PA.

410 Christiana Medical Center

Newark, Delaware 19702

Patient Information

Name____________________________________M___F___Date of birth M___D___Y____ Age___

Social Security Numer ____-___-____  Status:  Single___Married___Divorced___Widowed___

Address_________________________________City__________________State________Zip_______

Home phone________________________Work phone_____________Cell phone_________________

email address________________________________________________________________________

Employer__________________________Address___________________________________________

Emergency contact__________________Phone#___________________Relationship______________

Family Physician___________________Phone#____________________Last visit________________

Whom may we thank for referring you?__________________________________________________

Due to HIPAA privacy policies, may we:

Call your home number and leave a message on your answering machine?  Yes ___No___

May we leave a message with anyone who amswers the Phone?                         Yes ___No ___

Insurance

Primary Insurance_____________________________Policy holder_________________________Date of birth________________________

Social Security #_____-___-_____ Phone #_____________________Relationship to patient________________________________________

Secondary Insurance____________________________Policy holder_________________________Date of birth________________________

Social Security#_____-___-_____Phone #______________________Relationship to patient________________________________________

Consent

I certify that the above information is true and correct to the best of my knowledge.  I give my permission to the doctor to administer and perform such procedures as amy be deemed necessary in the diagnosis and treatment of my feet.  I authorize the use of this signature on all insurance submissions.

Patient’s signature_____________________________Parent/significant other___________________________________

Relationship to patient______________________________________________Date_______________________________