Welcome to El Paso Feet
Please complete this registration form
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Personal Information:

 
What is your full name? *

As it appears on your birth certificate or medical records.
 
What is your mailing address? *

 
What is the best phone number to reach you? *

 
The phone number you listed is a:


 
When were you born? *

 
What is your social security number?

 
What is your marital status?


 
What is your biological sex? *



 
Insurance information:

 
Do you have health insurance? *

You may be covered by your workplace or a family member.


 
Are you the health insurance Primary policy holder?



 
If you are not the primary insurance holder, what is the full name of the health insurance policy holder?

As it appears on the heath insurance policy certificate.
 
What is the birthdate of the primary insurance holder?

 
What is the social security number of the primary card holder?

 
What is the name of your Primary health insurance company?

 
What is the CoPay amount for a specialist office visit?

 
What is your health insurance policy number?

 
What is the street address of your insurance company?

 
What is their city and state?

 
What is their postal or zip code?

 
If you have more than one health insurance policy, please enter your additional policy information here (Name, Policy ID, Group ID, City, State, Zip, Phone Number):

 
Who is your primary care physician?

 
When did you last see your primary care physician?


 
Please list any other doctors who you rely on for your healthcare.

 
What pharmacy do you use?

 
What is your pharmacy's phone number?

 
Please enter the contact details of someone you trust.

We will contact this person in case of an emergency.
 
What is the full name of your emergency contact? *

 
What is your relationship with this person? *


 
What is their phone number? *

 
Thank you for sharing your personal and health insurance details.

We now just need to ask you a few more questions for our medical records.
 
Tell us your reason for requesting an appointment: *

 
What is your approximate height? *

 
What is your approximate weight? *

 
Do you smoke? *


 
Do you use chewing tobacco? *


 
Do you drink alcoholic beverages? *


 
Do you use recreational drugs? *


 
If you use recreational drugs, which drugs do you use?


 
Please tell us about your medical history: *


 
List any other medical problems you may have.

 
What is your family medical history?


 
Do you have any allergies? *



 
What are you allergic to?

Be careful to list all allergies, including any allergies to medication.
 
If you have allergies to medication, are they:


 
Describe what happens when you take medication you are allergic to:


 
Are you taking any medications currently? *



 
Please list the medications you are currently taking.

 
Are you currently pregnant or is there a chance you could be? *

If you are unsure, please ask your health professional about a free pregnancy test.


 
To the best of my knowledge, the above information is correct. I, the above Responsible Party, hereby give my permission to El Paso Feet, Spa915, Southwest Laser Care and it’s physicians, to administer treatment and to perform such procedures as deemed necessary in the diagnosis and/or treatment of the patient's foot condition. *

     
 
Please confirm the following details.


Full name: 
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Email: {{answer_10404602}}
Gender:
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Date of birth: {{answer_10404612}} {{answer_10404611}}, {{answer_10404610}}
Health Insurance Provider: {{answer_10404595}}
Health Insurance Policy Number: {{answer_10404596}}
Emergency contact: {{answer_10404600}}
Emergency phone number: {{undefined}}
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