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PATIENT FORMS

Thank you for choosing Dr. Marc Jay Pinsky for your foot care needs.  We appreciate your business and look forward to meeting you soon.

Below you will find the forms that comprise our "New Patient Packet".  We ask that you take the time to print out and complete each accurately and fully prior to your visit with us.

We request that you bring the following on your visit:
1.  Insurance card(s).
2.  List of medications and/or allergies.
3.  Completed forms comprising "the New Patient Packet".
4.  Photo ID.
5.  Any applicable co-pays or payments.
6.  Referrals or treatment authorizations (when needed/required).

It is our goal to provide you with quality healthcare and encourage you to call our office with any questions you may have.  We ask that you give us 24 hours notice if you are unable to keep your scheduled appointment. Otherwise, we maintain the right to charge you a missed appointment fee.

Thank you for your time and we look forward to seeing you soon.  Have a Great Day!


The "New Patient Packet" consists of three forms:

Patient Information - Gathers needed demographic data.  Please, sign/date at the bottom of the form.

Office Policies -  Please, sign/date at the bottom.

Medical History/Review of Systems - Needed to get a complete medical history including all your medications and allergies.  Please, sign/date at the bottom of the page.



Other Informative Forms

PostOperative Instruction Sheet -- Following Bone or Soft Tissue Procedures during which sutures are used.

PostOperative Instruction Sheet  --  Following Toenail, Wart, or other Procedures where NO sutures are used.

Advance Beneficiary Notice of Noncoverage - is ONLY required of Medicare recipients.  This forms is required to be signed, by federal law, before a patient can be seen for services which are not normally covered by Medicare.  Please, sign at the bottom.

Dr. Marc Jay Pinsky//Dr. Marc Jay Pinsky, PC   2010


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