Capital Foot and Ankle | New Patient Forms
22007
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New Patient Forms

We provide our new patient forms for your convenience and to ensure you have an efficient appointment with us.

You may review and complete the forms online prior to printing, or you may print the forms and complete them by hand. Please bring the completed forms to your appointment or fax them to our office at 402-483-5372.

If you choose to complete the patient forms at our office, please arrive at least 30 minutes prior to your scheduled appointment to allow yourself sufficient time. If your patient forms are not completed before your appointment time, your appointment may be delayed.

Please contact your insurance carrier about policy deductibles, copays and coinsurance prior to your appointment. Feel free to contact our office at 402-483-4485 with any questions.

Patient Information

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Patient Medical History

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Patient Current Medications

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Financial Policy

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Please review our Privacy Policy below.

We require only the first page to be printed, signed, and brought to your appointment.

If you choose, you may print a full copy of the Privacy Policy for your records.

Privacy Policy

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