COLORADO PODIATRY CONSULTANTS, PC Michael Zyzda, DPM

COLORADO PODIATRY CONSULTANTS, PC
Michael Zyzda, DPM
Scott Taylor, DPM
2460 West 26th Ave. Suite 180C, Denver, CO 80211
410 S Wilcox, Castle Rock, CO 80104
30940 Stagecoach Blvd., Evergreen, Co.80439
26659 Pleasant Park Rd, Conifer, CO 80433
1930 S Federal Blvd #A, Denver, CO 80219
Welcome to Colorado Podiatry Consultants!
We are Medical and Surgical specialists treating all conditions of the foot and ankle.
Our practice has been in existence for over 25 years. The doctors of Colorado Podiatry
Consultants have completed years of training along with advanced post residency
training (Surgical and Orthopedic Board certification). They have full hospital
privileges in many Denver area hospitals and surgery centers. We participate in most
major insurance plans. We pride ourselves in our personal touch from attentive,
devoted physicians to caring and helpful staff. Check out the medical staff information
page on our website, www.cpcdenver.com, for each doctors individual training and
background.
Services
Common conditions treated by our doctors include:
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Diabetic Foot and Nail Care
Sports Medicine
Heel pain and Plantar Fasciitis
Ingrown and fungal childrens foot
problems
Bunions
Hammertoes
Fractures of the foot and ankle
Orthotics/Bracing
! Flat Feet
! Arthritis
! Complicated wounds and infections
(circulation, pressure, bone and
diabetic wounds)
! Ingrown and Fungal nail problems
! Warts (Office CO2 laser)
! Burning feet (Anodyne treatments
available in office)
Products
We offer many products including but not limited to:
! Office Shoe Program
! Special Medicare approved
prescription Crocs
! Tea tree oil - used for nail fungus
! Strasburg socks – used to treat
and athletes foot
plantar fasciitis
! Superfeet shoe inserts
! A variety of toe pads
! Crocs Rx
! Athletic tape.
Office Hours: Monday – Friday 8:30am – 5:00pm
Phone: 720-855-9214
Fax: 720-855-9291
www.cpcdenver.com
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COLORADO'PODIATRY'CONSULTANTS,'PC'
MICHAEL!ZYZDA,!DPM!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!SCOTT!TAYLOR,!DPM!
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FEMALE!!!!!! MALE!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! MARRIED!!!!!! SINGLE!
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First'Name:________________________''''Mi:___________''Last'Name:___________________________________'
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Nickname:____________________'''Date'of'Birth:______________Social'Security#:_________________________'
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EGmail:________________________________________________________________________________________'
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Home'phone:__________________'Cell:________________________'Work:_______________________________'
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ADDRESS:_________________________________'''''''City:______________''''State:________'''Zip'Code:________'
Preferred!method!of!communication:!!!!!!!Text:______!!!!!!!EEmail:______!!!!!!!!!Home!phone:______!!!!!!Cell:!_______!
Party!responsible!for!payment:!!!Name:___________________________!Relationship!to!patient:!_______________!
Adddress:_______________________________!!Phone#:____________________!EEmail:_____________________!
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PRIMARY'INSURANCE:_____________________________'''''''''''Member'ID#:______________________________'
Secondary'Insurance'Information:!________________________!!!Member'ID#:_____________________________'
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Emergency'Contact'Info:''''''First'Name:_______________________'''Last'Name:____________________________'
Relationship:______________''Address:__________________________________Phone#:____________________'
*PRIMARY'CARE'PHYSICIAN*________________________'Date'Last'Seen:____/____/____''Telephone#________'
How!did!you!hear!about!us?!Google:____!!Insurance:!____!!Friend:____!Dr.!Referred:_________________________!
Other:_________________________________________________________________________________________!
I hereby authorize Colorado Podiatry Consultants, PC and/or associates to treat the patient identified above. I acknowledge that I am responsible to pay all charges for all treatments
administered by the physician and am required to give a 24 hour cancellation notice or a $25.00 fee will be assessed. I understand that insurance may not pay for all charges and that I
am obligated to pay for all charges not covered by insurance. I understand that I am responsible for all costs of collection should my account be turned over to a collection agency or
attorney, including attorney fees and collection fees in the amount of 30% of the current balance due. I hereby authorize my insurance benefits to be paid directly to the physician and I
am financially responsible for non-covered services. I also authorize the physician to release any information necessary in the processing of all insurance claims and/or the collection of
my account.
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Patient or responsible party signature
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Date
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COLORADO PODIATRY CONSULTANTS, PC
Specialists of the Foot and Ankle
Michael Zyzda, DPM, FACFS*
Scott Taylor, DPM
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Patient'Responsibility:'
Our!practice!is!committed!to!providing!the!best!treatment!for!our!patients.!Patients!are!responsible!for!all!charges!
resulting!from!treatment!provided!by!their!physician.!As!a!service!to!you,!we!will!bill!most!insurance!carriers!directly.!
However,!primary!responsibility!for!the!account!is!yours.!Providing!correct!insurance!billing!information!is!the!
responsibility!of!the!patient.!If!your!insurance!changes,!please!present!your!insurance!card!at!your!next!visit.!All!patients!
must!complete!our!patient!registration!form!before!seeing!the!doctor.!!! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!______________(Initial) !
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Payment'Arrangements:'
New'and'Established'Patients:'The!portion!that!insurance!will!not!pay!is!due!at!the!time!of!visit.!Insurance!companies!
do!not!guarantee!payment.!If!there!is!a!balance!due!after!insurance!pays,!payment!is!due!within!30!days!of!the!first!
billing.!Accounts!with!balances!over!90!days!will!be!assessed!a!processing!fee!each!month. ______________(Initial) !
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HMO/PPO!coEpayments!and!deductibles,!if!required!by!your!plan!are!due!at!the!time!of!each!visit.!'
We!accept!VISA,!MASTERCARD,!DISCOVER,!CARE!CREDIT,!CHECKS,!CASH!AND!MONEY!ORDERS.!!
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Referrals:'
Many!insurance!carriers!require!a!referral!from!your!Primary!Care!Physician!before!you!receive!care!from!a!specialist;!it!
is!your!responsibility!to!obtain!a!referral!or!prior!authorization!if!your!medical!coverage!requires!it.!A!phone!will!be!
provided!for!your!call,!please!get!the!name!of!the!person!who!authorizes!your!visit.!!
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Insurance'Billings:'
Please!be!aware!that!some!or!perhaps!all!of!the!services!you!receive!may!be!nonEcovered!services!and!not!considered!
reasonable!and!necessary!under!your!insurance!plan.!In!this!instance,!you!will!be!responsible!for!payment.!We!will!
submit!the!claim!to!your!insurance!carrier!on!your!behalf!with!necessary!information.!If!we!are!nonEparticipating!with!
your!insurance,!you!must!pay!for!services!upfront!and!acknowledge!you!are!being!told!we!are!nonEparticipating!with!
your!insurance.!We!will!still!submit!the!claim!for!you!if!need!be.! !
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MEDICARE:'Our!physicians!are!participating!providers.!We!bill!Medicare!as!your!primary!insurer!and!we!will!forward!
onto!your!secondary.!Please!be!sure!to!give!us!correct!information!concerning!your!primary!and!secondary!insurance.!
Also!be!prepared!to!provide!the!name!of!your!Primary!Care!Doctor!and!the!last!date!seen,!this!information!is!required!at!
EVERY!appointment.!! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!______________(Initial)
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I'have'read'and'accept'this'Credit'Policy.''
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Signature'of'patient'or'guardian'
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COLORADO PODIATRY CONSULTANTS, PC
MICHAEL ZYZDA, DPM
SCOTT TAYLOR, DPM
Medical History
Name:__________________________________________________ Today’s Date:_________________
Date of Birth:_____________
Age:_________
Sex: Female
Male
Describe the problems you are having with your foot (feet) and/or ankle(s).
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
On the diagram, please mark the place(s) where you are experiencing pain your feet.
LEFT FOOT
RIGHT FOOT
How long has it been painful?______________
When did it begin?___________________
If this was caused by an injury or accident, please indicate if this was work related or the result
of a car accident.
Work Accident
Auto Accident
Date of Accident______________
What treatment have you received from the other Dr.’s and/or how have you treated the
condition at home?
______________________________________________________________________________
______________________________________________________________________________
REVIEW OF SYSTEMS
Have you had or have any of the following medical problems?
Please check all that apply to you.
Diabetes
Heart attack or heart trouble
Leg or foot circulation problems
High blood pressure
Heart murmur
Mitral valve prolapse
Stroke
Excessive bleeding
Leg or lung blood clots
Shortness of breath
Transplant patient
(heart,lung,liver,kidney,etc)
Frequent infections
Allergies or hay fever
Stomach ulcers
Bleeding ulcers
Liver or kidney disease
Frequent urinary tract infections
Hepatitis
Arthritis
Numbness or weakness
Low pain tolerance
Chronic leg sores or foot sores
Foot or toe amputations
Constipation
HIV positive (AIDS)
Gout
Tendonitis
Chronic back pain
Artificial joint
Nerve pain
Skin diseases / rashes
Slow/difficult healing
Easily scar
High or low thyroid
Asthma
Pacemaker
Please give details about the marked conditions. Please also list any medical problems that are not listed.
Page 2 of Medical History
Patient’s Name:__________________________________________ DOB:____________ AGE:_____
Are you currently under the care of a physician for any of the previous mentioned conditions? Please
print their name and telephone number below.
_____________________________________________________________________________________
List all previous surgeries and/or serious illnesses or accidents.
_____________________________________________________________________________________
_____________________________________________________________________________________
Are you currently taking any medications?
Yes
No
(Circle answer that applies.)
Please mark below any that apply to you:
Antibiotics or sulfa medications
Tranquilizers/sedatives
High blood pressure medication
Heart medication
Arthritis or gout medication
Blood thinners
Cortisone/steroids
Nitroglycerin
Thyroid medication
Water pills
Aspirin
Insulin
Sleeping pills
Estrogen/hormones
Oral diabetes medication
Birth control pills
Please list the name and dosage of each medication you are currently taking. If you have a list already
written, we will make a copy for our records.
_____________________________________________________________________________________
_____________________________________________________________________________________
What is the name and telephone number of your pharmacy?_____________________________________
Are you ALLERGIC to or have you had a bad reaction to any medication? Yes No (Circle answer)
Please mark below any that apply:
Local anesthetics
penicillin or other antibiotics
sulfa medication
sedatives or sleeping pills
aspirin
iodine
adhesive tape
pain medications.
Please list all medication names that you are allergic to. Please include what type of allergic
reaction you have (difficulty breathing, upset stomach, hives):
_____________________________________________________________________________________
_____________________________________________________________________________________
Family History/Social History: Is there a family (blood relative) history of: (Please mark all that apply)
Heart disease
arthritis
bleeding disorder
neurological disorder
stroke
bunions
hammertoes
flat feet
circulation problem of the feet or legs
diabetes
Please list any other conditions that are not listed above:
_____________________________________________________________________________________
Please describe your type of employment:
_____________________________________________________________________________________
Average activity or amount of time on your feet during the day__________________________________
Do you drink alcohol or beer? Yes
No
Amount of use: Daily
Occasionally
Do you smoke?Yes
No
# of packs per day____ Previously smoked? Yes
No
Are you /could you be pregnant? Yes
No
Frequently
# of years___
Have you ever had a blood transfusion? Yes
No