Strash Foot & Ankle Care | Patient Information Form
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Patient Information Form

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If you chose Doctor's office or Urgent Care Clinic list the name below.

Medical History

Medications

Family Medical History (Not You)

Your Medical History

Approximate location (street or corner)
Typing your name in this box authorizes the release of any medical information necessary to process this claim and request payment of benefits, government or other to be made to: Alamo Family Foot Care, PA. (AFFC) I hereby give permission to Alamo Family Foot Care, PA to examine, administer treatment and perform such procedures as may be deemed necessary in the diagnosis and treatment of my condition. I hereby acknowledge the receipt of the privacy practices (Health Information and Portability Act) of AFFC.