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PATIENT REGISTRATION 

PATIENT INFORMATION
Male
Female
single
married
widowed
divorced
Are you required to have a referral to specialists?
Yes
No
Primary Insurance
Self
Spouse
Child
Secondary Insurance
Self
Spouse
Child
 
HEALTH QUESTIONNAIRE
No
Yes
Please check all that apply:
AIDS/HIV
Allergies to medications
Allergies to anesthetics
Anemia
Arthritis
Asthma
Back Problems
Cancer
Chemical dependency
Circulatory problems
Diabetes
Epilepsy
Foot or leg cramps
Gout
Heart Problems
Hemophilia
Hepatitis
High blood pressure
Kidney problems
Multiple sclerosis
Liver disease
Phlebitis (blood clot)
Psychiatric care
Stroke
Swelling in legs and feet
Skin ulcers
Stomach ulcers
Varicose veins
Psoriasis
Eczema
MRSA
Neuropathy
Atrial fibrillation
On anti-coagulant therapy
Anything else you would like us to know?
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If you have questions, or would like more information, please leave your name and contact information.

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Steve R. Feller, DPM
7507 Custer Road West
Lakewood, WA 98499
Phone: (253)472-6530
Email: info@stevefeller.com

 

Receptionist:  Kenia

Nurse/Surgery coordinator:   Kari

Billing Coordinator:   Rachel

Pet therapy staff:  Mikhail,  Jason

 

Please remember to bring your insurance card and referral form with you at the time of your appointment Thanks!