New Patient Intake — Dr. Husein, DPM

Dr. Husein, DPM

New Patient Intake Form

1
Office & Demographics
2
Visit & Insurance
3
Medical History
4
Social History
5
Consents & Signature

Office & Patient Demographics

Step 1 of 5 — Basic information

Choose your office location
Ethnicity
Primary language
Pharmacy
Referral & Physicians
Emergency contact
Step 1 of 5

Today's Visit & Insurance

Step 2 of 5 — Reason for visit and coverage

Type of Visit
🏥
Office Visit
Wadsworth or Lakewood
Mon–Fri · 9am–4pm
💻
Telehealth
Video visit
Weekends · $100
🏠
Facility / Home
Home or SNF visit
Weekends · $200
Reason for today's visit
How long has it been bothering you?
Pain severity
Insurance information

Primary insurance

Secondary insurance (if any)

Yes, I'd like to pay my bill via text message or email
Photo ID & Insurance Cards

Please take a photo or upload an image of your ID and insurance card(s). This saves time at your visit. All images are transmitted securely.

📷 Government-issued Photo ID Required

Driver's license, state ID, or passport

Tap to take photo or upload

📷 Primary Insurance Card Required

Front of your primary insurance card

Tap to take photo or upload

📷 Secondary Insurance Card (optional)

Front of secondary card if applicable

Tap to take photo or upload
Step 2 of 5

Medical History

Step 3 of 5 — Current conditions, medications & family history

Current medical conditions (check all that apply)
No current problems
Anemia / Clotting disorder
Arthritis
Asthma
Bladder infection
Bleeding disorder
Anxiety / Depression
Fibromyalgia
Gout
HIV / AIDS
Heart problems / Attack
Hepatitis
High blood pressure
Kidney disease
Liver disease
Sickle cell anemia
Stroke
Thyroid disease
Alzheimer's / Dementia
Cancer
Parkinson's disease
Neuropathy
Tuberculosis
Bipolar disorder
Diabetes
Drug / Alcohol abuse history
Prior surgeries / hospitalizations
No prior surgeries or hospitalizations
Current medications
No current medications
Allergies
No known drug allergies
Family history (check all that apply)
Neuropathy
Stroke
Heart attack
Heart disease
High blood pressure
Heart murmur
Cardiac arrhythmia
Cholesterol disease
Circulation disease
Diabetes
Kidney disease
COPD / Emphysema
Asthma
Ulcer / GERD
Bleeding disorder
Anemia
Hepatitis A/B/C
HIV / AIDS
Osteoporosis
Fibromyalgia
Arthritis
Gout
Mental illness
Depression
Thyroid disease
Alzheimer's
Cancer
Frequent infections
Tuberculosis
Parkinson's
Clotting disorder
Step 3 of 5

Social History

Step 4 of 5 — Lifestyle information

Smoking
Alcohol use
Recreational drug use
Falls in the past year
Step 4 of 5

Consents & Signature

Step 5 of 5 — Review and sign

Your information is protected under HIPAA. This form is transmitted securely to the office you selected.

HIPAA authorization & release of health information

I authorize Ohio Foot & Ankle Specialists (OFAS) and its agents to release my health information for the purpose of payment, treatment and healthcare operations to any of the following: Insurance company and its affiliates, any practitioner, support staff or faculty involved in my plan of care or transfer of care. I have read and/or had the opportunity to read my HIPAA rights.

Consent to treat

The undersigned consents to any initial or follow-up evaluations, examinations, x-rays, laboratory procedures, other tests, medications, medical treatment, surgery, physical therapy, home instructions, orthotics, other durable medical equipment, and/or other services rendered by Ohio Foot and Ankle Specialists and its providers.

Assignment of benefits & financial agreement

I hereby irrevocably assign to Ohio Foot & Ankle Specialists any and all insurance benefits and rights to which I am entitled. I understand I am responsible for all copayments, deductibles, coinsurances, and non-covered services at the time of service. A $25 fee applies to no-show appointments with less than 24 hours notice.

Credit card on file authorization

I authorize OFAS to store my credit card securely with Global Payments for billing purposes. Card charges are made only after insurance has processed claims, up to $250 per billing cycle for outstanding balances. This does not apply to Medicare/Medicaid patients.

Medication history consent

I give consent to Ohio Foot and Ankle Specialists to retrieve and use my medication history from SureScripts for treatment purposes.

Patient signature

To the best of my knowledge, I have answered all questions on this form accurately. I understand that providing incorrect information can be dangerous to my health.

Sign below with your mouse, finger, or stylus
Step 5 of 5

Thank you,

Your intake form has been received and sent to our office team.

If you have questions before your appointment, please call us directly.