WAYNE MARCHAND DPM PATRICIA SULLIVAN DPM GEORGIOS PONIROS, DPM ADDRESS CITY ZIP. Primary Care Physician

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1 WAYNE MARCHAND DPM PATRICIA SULLIVAN DPM GEORGIOS PONIROS, DPM PATIENT INFORMATION NAME ADDRESS CITY ZIP Home Phone Work phone Cell Date of Birth Gender Referred by Primary Care Physician Marital status Race Ethnicity Language spoken PERSON RESPONSIBLE FOR PAYMENT (if different than subscriber) NAME Relationship to patient DOB: Address (if different) Phone # INSURANCE INFORMATION Primary Insurance Subscriber Name Relationship to subscriber DOB: Secondary Insurance Subscriber Name Relationship to subscriber MEDICAL INFORMATION DOB: This information is important for our records and for your health. Please answer each question carefully. Describe your foot problem How long has this been bothering you? Was this due to an injury? Work / Auto? Describe Injury Have you had any past problems with your feet? Do you have allergies or are sensitive to: Antibiotics (Penicillin, Sulfa drugs, etc?)

2 Other Medications? Betadine? Iodine? Tape? Latex? Other Allergies? Have you had any problems taking Aspirin or Ibuprofen (Advil or Motrin)? Describe: General Health Questions Do you have diabetes? If so, do you take insulin? How long? Any serious illnesses? If so, explain: Any major surgeries? If so, explain: Are you under a physicians care? If so, for what condition? May we contact your physician about your health if needed? Have you had any problems with: HEART ASTHMA SKIN WEIGHT LOSS CIRCULATION STOMACH ULCERS GOUT FREQUENT INFECTIONS ARTHRITIS ANEMIA TUBERCULOSIS HEALING PROBLEMS KIDNEYS BLADDER LUNGS BLOOD PRESSURE CANCER RHEUMATIC FEVER GASTRO FAMILY HISTORY MOTHER LIVING DECEASED CAUSE FATHER LIVING DECEASED CAUSE BROTHER (#) # LIVING # DECEASED CAUSE SISTER (#) # LIVING # DECEASED CAUSE Is there a family history (blood relative) of: Heart Disease Arthritis Stroke Diabetes Bleeding Disorders Neurological Disorders Bunions Hammertoes Flat Feet Circulation problems in legs or feet

3 Do you smoke? If YES, how much If NO, Did you quit? When Do you drink alcohol? Have you received the FLU shot? If YES, when Activity during employment: sit at job stand at job stand & walk retired student SIGNED CONSENT AND AUTHORIZATION TO TREAT I give permission for treatment of my foot condition to Dr. Wayne D. Marchand, Dr. Patricia M. Sullivan, and/or Dr. Georgios P. Poniros. I authorize release of any payments and medical information necessary to process/pay claims for services furnished to me by the above named doctors. I authorize payments be made directly to Auburn Podiatry LLP from any third party payer. I acknowledge responsibility for payment for services not covered by insurance. I am aware that I may be charged for appointments not kept or not cancelled within 24 hours. I acknowledge receipt of notice of privacy practices from Auburn Podiatry LLP, inclusive of Dr. Wayne D. Marchand, Dr. Patricia M. Sullivan, and/or Dr. Georgios P. Poniros. I understand all of the above and state the information is correct and accurate to the best of my knowledge. Signed Date Auburn Podiatry LLP Wayne D. Marchand DPM Patricia M. Sullivan DPM Georgios P. Poniros DPM NOTICE OF PRIVACY PRACTICES This notice describes how health information about you may be used and disclosed and how you can get access to this information. Please review it carefully. The privacy of your health information is important to us. OUR LEGAL DUTY: We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this notice about our privacy practices, our legal duties and your rights concerning your health information. WE must follow the privacy practices that are described in this notice while it is in effect, as of April 1, We reserve the right to change our privacy practices and the terms of this notice at any time, provided such changes are permitted by law. Before we make changes, we will change this notice and make the new notice available upon request. You may request a copy of this notice at any time. USES AND DISCLOSURES OF HEALTH INFORMATION: We use and disclose health information about you for treatment, payment, and healthcare operations. For example: Treatment: We may use or disclose your information to a physician or other healthcare provider providing treatment to you.. Payment: WE may use and disclose your information to obtain payment for services we provide to you. Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations, including quality assessment, reviewing the competence of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities. Your Authorization: You may give us written authorization to use your health information or to disclose it to anyone for any purpose. You may revoke that authorization at any time, although not affecting the use while it was in effect. If authorization is not given, we cannot use or disclose your information for any reason except those described above. To Your Family & Friends: We may disclose your information to a family member, friend, or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so. Persons involved In Care: We may use or disclose health information to notify or assist in the notification of a family member, your personal representative or another person responsible for you r care, of your location, general condition, or death. If you are present, then prior to use we will provide you with the opportunity to object to such uses. In emergency situations, we will disclose health information based on determination using professional judgment, giving only the information relevant to your healthcare. We will make reasonable inferences in your best interest allowing a person to pick up medical supplies, x-rays, prescriptions, or similar forms of information. Marketing Services: We will not use your health information for marketing communications without written authorization. Required by Law: We may use or disclose your information when we are required to do so by law. Abuse or Neglect: We may disclose information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or victim of other crimes, in order to avert a serious threat to your safety or the safety of others. National Security: We may disclose information to military authorities if required for lawful intelligence, counterintelligence, and other national security activities..

4 Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders, such voic messages, appointment cards, and/or letters. PATIENT RIGHTS Access: You have the right to look at or get copies of your health information with limited exceptions. You may request copies other than photocopies, making the request in writing. You may also request your records by sending us a letter to the address listed below. A fee may be charged for record processing. Disclosure Accounting: You have the right to receive a list of disclosed instances in the past but not before April 14, 2003, once a year. Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement. Alternative Communications: You have the right to request that we communication with you about your health information by alternative means or to alternative locations, requested in writing. Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request. Amendment: You have the right to request that we amend you r health information, in writing, and must explain why it should be amended. We have the right to deny your request under certain circumstances. Questions and Complaints: If you need more information about our privacy practices, please contact us. If you are concerned that we may have violated your rights, you may amend or restrict the use of disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to the US Department of Health and Human Services. We will provide you with the address to file your complaint with the US Dept of Health and Human Services upon request. We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint. Contact: Wayne D. Marchand DPM Phone: Fax: Auburn Street Auburn MA MY MEDICATION LIST Patient Name: Date of Birth: Date: Please list all drugs you are currently taking. Drugs include prescription and over-the-counter medications, herbal products, nutritional supplements, and recreational drugs. Bring this list with you to your first appointment. If you are not taking medications, please check here: No medications taken Name of Drug? Strength of Drug? How Often Do You Take? Why Do You Take This Drug? Who Prescribed Drug? (if prescription)

5 Do you have any allergies? Yes No If yes, please list: WAYNE D. MARCHAND DPM PATRICIA M. SULLIVAN DPM GEORGIOS P. PONIROS DPM FACFAS Doctor of Podiatric Medicine & Foot Surgery Doctor of Podiatric Medicine & Foot Surgery Doctor of Podiatric Medicine & Foot Surgery Diplomate American Board of Podiatric Surgery Diplomate American Board Diplomate American Board of Podiatric Surgery Fellow American College of Foot Surgeons of Multiple Specialties in Podiatry Fellow American College of Foot & Ankle Surgeons We would like to welcome you to our practice! Complete the documents and bring them with you on the day of your appointment, along with your insurance card. ALL CO-PAYS MUST BE PAID AT THE TIME OF YOUR VISIT. For your convenience, we accept cash, Visa and Mastercard for payment options. If you are in need of any help completing these forms, we will assist you on the day of your visit. If your insurance is one that requires a referral for podiatry services, we ask that you contact your primary care physician prior to your visit. The referral needs to be in place at the time services are rendered. A referral is not a guarantee of payment. Benefits are subject to all contract limits, including deductible and the member's eligibility on the date of service. Please plan to arrive 15 minutes prior to your appointment time.

6 Failure to keep your appointment without notification to our staff within 24 hours of this scheduled time will result in a $50 fee and your primary care physician will be notified in writing. Due to the high volume of patients waiting to be scheduled to see our doctors, rescheduling your missed appointment might not always be immediately feasible. If, however, a new appointment is assigned to you, you will still be responsible for the $50 fee previously incurred.