▪ Diabetic Foot Care ▪ Sports Medicine Computerized Gait and Pressure Analysis ▪

Reconstructive Foot and Ankle Surgery

Pediatric Foot Disorders ▪ Diabetic Foot Care ▪ Sports Medicine Computerized Gait and Pressure Analysis ▪ Physical Therapy

Nicholas J Alianello, DPM

Jeffery H. Alexander,MS,DPM

Gregory T. Amarantos, DPM

Jeffrey R. Baker, DPM

Wendy Benton-Weil, DPM

Jennifer E Bernstein, DPM

Frank Bongiovanni, DPM


Anthony H. Borrelli, DPM

Michael F. Bowen, DPM

Cynthia R. Cernak, DPM

Kordai I DeCoteau, DPM

George L. Enriquez, DPM

Adam E. Fleischer, MPH, DPM

Dr. Wika K Gomez, DPM

Donna J Hayes, DPM

Lowell Weil, Jr., MBA, DPM Lowell Scott Weil, Sr., DPM

Stephen A. Weinberg, DPM

Bruce E. Williams, DPM

Fellow, Brett J Waverly, DPM

Fellow, Sarah Haller, DPM

Stephanie C. Spiegel, COO

Jennifer L Kaleta, DPM

Erin E. Klein, MS, DPM

David W. O’Brian, DPM

Robert G. O’Keefe, DPM

Mitchell B. Sheinkop, MD

Matthew D. Sorensen, DPM

Bilal Siddiqui, DPM

Dean S. Stern, DPM

Dear      :

On behalf of all the associates at the Weil Foot & Ankle Institute, I would like to welcome you and your family. We take pride in knowing that you have placed your trust in us to provide for your care while being treated at the Institute. By having the best team and a focused facility, we are here to meet all of your podiatric needs.
Our patient-focused environment fosters open communication, cooperation, innovation, respect and compassion. Our staff is prepared to provide information you may need to prepare for the care you will be receiving at the Institute. Please ask any staff member if there is anything we can do to make your visit with us the best that it can be. We promise that our patients always come first.
Thank you for choosing the Weil Foot & Ankle Institute.

Sincerely,

Stephanie C. Spiegel

Chief Operating Officer

W

ELCOME TO OUR PRACTICE

This letter confirms your appointment with Dr.  at       on       in the following office:
 Bridgeport, 736 W. 35^th St., Chicago (60616)

 California Ave., 5215 N. California Ave, Suite F605 Chicago (60625)

 Des Plaines, 1455 Golf Road, Suite 110 (60016)

 Glenview, 1300 Waukegan Rd. (60025)

 Higgins 7101 W Higgins Ave, Chicago (60656)  Higgins 7101 W Higgins Ave, Chicago (60656)

 Highland Park, 1729 Green Bay Rd (60035)

 Illinois Masonic, 3000 N. Halsted, Suite 606, Chicago (60657)

 Kenosha, Wisconsin, 10105 74^th St., Suite 101 (53142)

 Lake Forest, 800 Westmoreland Ave. Ste 200 (60045)

 Libertyville, Hawthorn Health Center, 1900 Hollister Dr., Suite 160 (60048)

 Lincoln Park, 1565 N. LaSalle, Chicago (60610)

 Merrillville, Indiana, 8120 Georgia St., Suite B (46410)

 Oak Lawn, 5405 W. 95th St, Chicago (60453)

 Paddock Lake, Wisconsin, 7001 236^th Ave. (53168)

 Roselle, 10 N. Roselle Rd, Suite 300 (60172)

Please

Arrive at least 30 minutes prior to your appointment time to complete the registration process. Also enclosed please find our “New Patient” insurance information

and medical history forms that we ask you to complete prior to your appointment. You may

email or fax the completed forms to us at 847-390-9345 or bring the completed forms with you. If we do not have your completed forms before your appointment time, your appointment may be delayed by up to 30 minutes.
Please review this material and contact your insurance carrier about policy deductibles and co-

insurance prior to your appointment. Feel free to call our office at 847-390-7666 with any

questions.
Thank you,

Stephanie C. Spiegel

Chief Operating Officer

Weil Foot & Ankle Institute

(Please Print) REGISTRATION FORM

Today’s Date      /     /      Facility  Doctor 

PATIENT INFORMATION

Patient’s Last Name

First

Middle

 Mr.  Mrs.

 Sr.

     

     

     

 Dr.  Miss

 Jr.

Street Address

City

State

Zip Code

     

     

     

     

Home Phone #

Work Phone #

E-mail Address

( (     )     -     

(     )     -     

     

Birth Date

Age

Social Security Number

Marital Status

Sex

     /     /     

     

     

Single Mar Widow Div

 M  F

INSURANCE INFORMATION

Occupation

Insured Employer

     

     

Insured Employer Address

     

Please indicate primary insurance

Address of primary insurance carrier      

Phone number

     

(     )     -     

Insured Name

Insured S. S. #

Insured ID

Policy Group #

Eff. Date

Co-Payment

     

     

     

     

     

$      

Patient’s Relationship to Insured

 Self

 Spouse

 Child

 Other

Insured Birth Date      /     /     

Insurance Type

 PPO  EPO  HMO  POS  Self Pay  Medicare  Public Aid  WC  OTHER  .

Please indicate secondary insurance

Address of secondary insurance carrier      

Phone number

(     )     -     

     

Insured Name

Insured S. S. #

Insured ID

Policy Group #

Eff. Date

Co-Payment

     

     

     

     

     

$      

Patient’s Relationship to Insured

 Self

 Spouse

 Child

 Other

Insured Birth Date      /     /     

Insurance Type

 PPO  EPO  HMO  POS  Self Pay  Medicare  Public Aid  WC  OTHER  .

Referred to Institute by (Please use one) Address

 Doctor	     		     
 Hospital	     		     
 Insurance Plan	     		     
 Family	     		     
 Friend	     		     

 Tribune  Herald  Sun Times  T.V  Radio  Other  

AUTHORIZATION FOR ASSIGNMENT OF BENEFITS	X      	     /     /     
To Weil Foot & Ankle Institute, Ltd.	Signature	Date
HIPAA AUTHORIZATION	X      	     /     /     
Necessary to process claims	Signature	Date
Communication Authorization I authorize Weil Foot & Ankle Institute to contact me via phone, text, fax, mail and email	X 	     /     /     
	Signature	Date

MEDICAL HISTORY

PATIENT NAME      

BIRTH DATE

     /     /     

ALLERGIES (LIST KNOWN ALLERGIES OR REACTIONS TO DRUGS/MEDICATIONS

 Penicillin

 Sulfa

 Local Anesthetic

 Anti-inflammatory Medication

 Codeine

 Tape

 Nausea From Anesthetic

 Iodine on Skin

     

     

     

     

MEDICATIONS (PLEASE LIST CURRENT MEDICATIONS THAT YOU ARE TAKING: PRESCRIPTION AND OVER THE COUNTER)

MEDICATION

DOSE

MEDICATION

DOSE

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

FOOT/ANKLE PAIN WHERE?      

HOW LONG?

MONTHS      

YEARS      

WHAT PREVIOUS TREATMENT HAVE YOU HAD ON YOUR FOOT/ANKLE?

 Surgery

 Orthotics

 Oral Medications

 Cortisone Shots

FAMILY PHYSICIAN INFORMATION

Medical Doctors Name

Phone Number

     

(     )     -     

Street Address      

City      

State      

Zip Code      

Have you ever been put to sleep for surgery?  Yes  No

SHOE SIZE      

HEIGHT      

WEIGHT      

DO YOU DRINK?

 NO

 YES

DRINKS PER WEEK      

DO YOU SMOKE?

 NO

 YES

PACK(S)/DAY      

Indicate which of the following you have had or have at present. Check Yes or No to each item

Arthritis/Rheumatism

 Yes

 No

High Blood Pressure

 Yes

 No

Artificial Joints (hip, knee, etc.)

 Yes

 No

H.I.V. Positive

 Yes

 No

Asthma

 Yes

 No

Kidney Trouble

 Yes

 No

Diabetes

 Yes

 No

Liver Disease

 Yes

 No

Fibromyalgia

 Yes

 No

Motion Sickness

 Yes

 No

Glaucoma

 Yes

 No

Neurological Disorder

 Yes

 No

Heart (Surgery, Disease, Attack)

 Yes

 No

Psychiatric/Psychological Care

 Yes

 No

Heart Murmur

 Yes

 No

Stomach Problems / Reflux / Heartburn

 Yes

 No

Hepatitis A (Infectious) B (serum)

 Yes

 No

Ulcers (Diabetic)

 Yes

 No

Varicose Veins

 Yes

 No

Leg Swelling

 Yes

 No

Leg Pain/Aching

 Yes

 No

Leg Cramps

 Yes

 No

Heaviness in Legs

 Yes

 No

Restless Legs

 Yes

 No

I understand the above medical information is necessary to provide me with medical care in a safe and efficient manner. I have answered all

questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective health care provider

or agency, who may release such information to you. I will notify the doctor of any changes in my health or medication.

X      

     /     /     

Patient/Guardian Signature

Date

HISTORY REVIEWED BY: DR. SIGNATURE

DATE

(Please Print) REGISTRATION FORM

Today’s Date      /     /      Facility  Doctor 

PATIENT INFORMATION

Patient’s Last Name

First

Middle

Birth Date

     

     

     

     /     /     

DEMOGRAPHICS (FOR GOVERNMENTAL STATISTICAL ANALYSIS)

Race

 American Indian or Alaska Native  Asian  Native Hawaiian  Black or African American  White  Hispanic  Other Pacific Islander  Other Race  I Decline to Report

Ethnicity

 Hispanic  Non-Hispanic  I Decline to Report

Preferred Language

 English  Spanish  Other  

PHARMACY / PRESCRIPTION INFORMATION

Preferred Pharmacy:

 Costco  CVS  Osco  Target  Wal-Mart  Walgreens  Other  
Address or Cross-Streets:  
City:  
State:  
Zip Code:  
Phone Number:  
Fax Number:  
 This is a mailorder pharmacy
 I do not have a preferred pharmacy

I authorize Weil Foot & Ankle Institute and its affiliated providers to view my external prescription history via the Surescripts service. I understand that prescription history from multiple other unaffiliated medical providers, insurance companies, and pharmacy benefit managers may be viewable by my providers and staff here, and it may include prescriptions back in time for several years.

MY SIGNATURE CERTIFIES THAT I READ AND UNDERSTOOD THE SCOPE OF MY CONSENT AND THAT I AUTHORIZE THE ACCESS.

CONSENT TO OBTAIN EXTERNAL PRESCRIPTION HISTORY	X      	     /     /     
To Weil Foot & Ankle Institute, Ltd.	Signature	Date

DIRECTIONS TO HIGHLAND PARK OFFICE

FROM THE EDENS/SKOKIE HIGHWAY (I-94/US-41):

1. 
   TAKE US-41 (EDENS/SKOKIE HIGHWAY) TO CENTRAL AVE
   
2. 
   GO EAST ON CENTRAL AVE
   
3. 
   TURN RIGHT ON GREEN BAY RD. WE ARE ON THE EAST SIDE OF GREEN BAY RD. BETWEEN CENTRAL AVE AND LAUREL AVE. THERE IS A PARKING GARAGE ACCESSIBLE FROM GREEN BAY RD.
   

FROM PARK AVE:

1. 
   TAKE PARK AVE TO GREEN BAY RD.
   
2. 
   GO SOUTH ON GREEN BAY RD. PAST CENTRAL AVE.
   
3. 
   WE ARE ON THE EAST SIDE OF GREEN BAY RD. BETWEEN CENTRAL AVE AND LAUREL AVE. THERE IS A PARKING GARAGE ACCESSIBLE FROM GREEN BAY RD.
   

1729 GREEN BAY RD

1. 
   1455 E. Golf Road ▪ Des Plaines ▪ Illinois ▪ 60016 ▪ T-847.390.7666 ▪ F-847.390.9345
   

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