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,

Gary Rubin

Director of Operations


WELCOME TO OUR PRACTICE

This letter confirms your appointment with Dr. at on in the following office:

Bridgeport, 736 W. 35th St., Chicago (60616)

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

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

Flossmoor, 19550 Governors Highway, Flossmoor, IL 60422

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 74th St., Suite 101 (53142)

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

Lemont, 15531 127th St, Lemont, IL 60439

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 236th Ave. (53168)

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

Tinley Park, 16735 Oak Park Ave, Tinley park, IL 60477

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,

Gary Rubin

Director of Operations

Weil Foot & Ankle Institute

(Please Print) REGISTRATION FORM

Today’s Date // Facility Berwyn Bridgeport California Ave Des Plaines Elk Grove Village Elmhurst Glenview Highland Park Kenosha Lake Forest Libertyville Lincoln Park MerrillvilleOak ParkPaddock Lake RoselleRushSkokie Valparaiso Doctor Gregory Amarantos Jeffrey Baker Wendy Benton-Weil Frank Bongiovanni Anthony Borrelli Michael Bowen George Enriquez Adam Fleischer Erin Klein James Lawton David O'Brian Robert O'Keefe Mitchell Sheinkop Matthew Vogt Lowell Weil Jr Lowell Weil Sr Stephen Weinberg Bruce WilliamsDean SternJeffrey AlexanderCynthia CernakEric LarsenBrian GradisekBrian Gradisek

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 Berwyn Bridgeport California Ave Des Plaines Elk Grove Village Elmhurst Glenview Highland Park Kenosha Lake Forest Libertyville Lincoln Park MerrillvilleOak ParkPaddock LakeRoselleRushSkokie Valparaiso Doctor Gregory Amarantos Donald Arenson Jeffrey Baker Wendy Benton-Weil Frank Bongiovanni Anthony Borrelli Michael Bowen George Enriquez Adam Fleischer Erin Klein James Lawton David O'Brian Robert O'Keefe Mitchell Sheinkop Matthew Vogt Lowell Weil Jr Lowell Weil Sr Stephen Weinberg Bruce WilliamsCynthia CernakEric LarsenDean SternJeffrey AlexanderBrian Gradisek

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 FLOSSMOOR

From the North

Via Kedzie Ave.

Take Kedzie Ave south.

Make a slight right onto Governors Hwy

From the West

Via I-80

Had East on I-80

Take exit 148A to merge onto IL-43/Harlem Ave

Use the left 2 lanes to turm left onto Vollmer Rd

Turn left onto Kedzie Ave.

Sharp left onto Governors Hwy

19550 Governors Highway, Flossmoor, IL 60422