New Patient

Patient Registration

Complete this form online before your first visit to save time at the office. Your information is kept strictly confidential.

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Patient Financial Responsibility

Thank you for choosing Bregman Foot-Ankle & Nerve Center (BFANCE) as your healthcare provider. The patient (or parent/guardian/healthcare proxy) is ultimately responsible for payment of treatment and care.

Patients are responsible for copays, coinsurance, deductibles, and all procedures not covered by their insurance plan. Payment is due at the time of service. We accept cash, cashier's check, and most major credit cards.

Missed appointments without 24-hour advance notice will incur a $50 fee which must be paid in full before future appointments are scheduled.

By signing below, you acknowledge and agree to these financial terms and authorize BFANCE to release information to necessary insurance companies and healthcare entities.

Patient Demographics

Your insurance card and photo ID are required at the time of your appointment.

Contact Information

Emergency Contact

Primary Care Provider

Pharmacy Information

Insurance Information

Primary Insurance

Secondary Insurance (if applicable)

Medical History

Patient Medical History (check all that apply)

Family Medical History (check all that apply)

Chief Complaint & Symptoms

Pain Descriptors (select all that apply)

Previous Treatment (check all that apply)

HIPAA Authorization & Release of Information

I agree and consent to Bregman Foot-Ankle & Nerve Center releasing information to me in the following manner. Please indicate your preferences:

Authorization to Release Information to Family Members

Under HIPAA requirements, we are not allowed to give medical information to anyone without the patient's consent. If you wish to have your medical information released to family members, please list them below.

Please check all that apply:

By submitting this form, I attest that all information provided is true and accurate. I understand this is a registration submission — our team will contact me to confirm my appointment.