Bloomington (812) 333-4422
Bedford (812) 277-1000
Washington (812) 254-2911


Intake Form

    Please complete the following form and answer all questions before arriving for your appointment.

    Be sure to include your insurance information. We'll see you soon!

    Patient Information

    First Name (*)
    Middle Initial
    Last Name (*)

    Social Security Number (*)

    Your Email Address (Responsible Party) (*)

    Mailing Address (*)

    City (*)
    State (*)
    Zip (*)
    Phone number (*)
    Date of Birth: Month (*)
    Date of Birth: Day (*)
    Date of Birth:Year (*)
    Sex (*)
    Marital Status (*)
    Height (*)
    Weight (*)
    Shoe size (*)
    Race (*)

    *This information is requested due to Healthcare Reform laws dictated by Congress.


    Preferred Language (*)

    Are you pregnant? (*)
    Are you nursing? (*)

    Have you completed an Advance Directive (living will)? (*)

    Primary Care Physician (*)

    Primary Care Physician Address (*)

    Physician Phone Number (*)
    Date last seen: Month (*)
    Date last seen: Day (*)
    Year (*)
    Pharmacy (*)
    Pharmacy Phone (*)
    Who referred you to our office? (*)

    Primary Reason for Visit (*)

    Duration of Condition (*)

    What helps / makes it worse?

    Is it limiting your activity level? (*)

    Secondary problem (if there is one)

    Please list any drug allergies (*)

    List Medications You Take (*)

    Medical History (please check all that apply) (*)

    Specify other

    If you have cancer, please list type and treatment (*)

    Please list past surgeries and year surgery was performed (*)

    Social History

    Do you drink alcohol? (*)

    How often?

    Do you smoke, vape or use chewing tobacco? (*)

    Please specify
    How many per day?
    Method of Quitting

    Do you have/have had a substance abuse problem? (*)

    Please specify

    Family History

    Which family members had the below medical conditions? (father, mother, sibling, etc.)

    Heart Attack
    Hypertension/High Blood Pressure

    Insurance Information

    Subscribers Name (*)
    Subscribers D.O.B. (*)
    Patient's Relation to the Subscriber (*)

    HMO (*)

    Primary Insurance (*)
    Policy Number (*)
    Policy Holder Name (*)
    Date of Birth: Month (*)
    Date of Birth: Day (*)
    Date of Birth: Year (*)

    Secondary Insurance

    Secondary Policy Number

    Occupation (*)

    Employer (*)

    Employer Address


    Employer Phone Number (*)

    Emergency Contact

    First Name (*)
    Last Name (*)
    Relationship to Patient (*)
    Phone (*)

    Responsible Party (if minor patient)

    First Name
    Last Name
    Relationship to Patient
    Date of Birth: Month
    Date of Birth: Day
    Date of Birth: Year

    Consent for Treatment and Acknowledgement of Policies

    For any insurance plan that requires authorization from a primary care physician (e.g. HMO, PPO, etc.) it is your responsibility (as patient or guardian) to be sure that this office receives all necessary referrals or authorizations PRIOR to treatment. Professional services are rendered and billed directly to your insurance carrier; however you, the patient/guardian, are directly responsible for services rendered by the doctor. A health insurance policy is a contract between you (the patient or subscriber) and your insurance carrier. You MUST notify this Office of any changes to your insurance policy including policy termination, changes in co-payments or a new insurance policy. If for any reason the insurance carrier denies charges, payments for any services rendered will become the responsibility of the patient/guardian.

    All office visit charges and co-pays are due at the time services are rendered. It is the patient who is responsible for any and all financial aspects of services rendered. There will be a charge for returned checks, missed appointments without 24 hours notice and completion of any forms. I agree to pay for all deductibles, co-pays, non-covered services and any portion of covered services not paid in full by my insurance plan and understand that such payments are due at the time of service or immediately upon presentation of the bill. I hereby name Kevin J. Powers, DPM (KJPDPM) as my assignee. I instruct my health care benefits plan administrator, i.e. PLAN to pay KJPDPM directly for all professional and medical services provided by KJPDPM through the means of electronic funds transfer(s) (EFT) or by check(s) made payable to and mailed to TCLENS. I AUTHORIZE THE RELEASE OF ANY MEDICAL INFORMATION NECESSARY TO PROCESS CLAIMS.

    The above information is correct to the best of my knowledge. I understand that throughout my treatment, I am responsible for notifying the physician and/or medical staff of any and all updates to the information listed above. I also give permission for photographs of my feet to be taken that are to be kept as part of my medical record only. They will not be published as part of medical research or disbursed in any way without my permission.

    I acknowledge that I was provided a copy of the Notice of Privacy Practices for Kevin J. Powers, DPM and I have read (or had the opportunity to read if I so choose) and understood the Notice.


    We are pleased to welcome you to our office. New Patients are always appreciated. Our practice has grown as a result of its excellent relationship with our referring doctors and patients. As our patient, please feel free, at any time, to express any concerns or to ask any questions that you may have for the doctor or our staff. In order to assist you in making payment(s) for your podiatric treatment, the following options are listed. Please read them carefully and feel free to discuss them with us.

    If you DO NOT have insurance: Payment is due, in full, at the time treatment is provided.

    We accept cash, check and most major credit cards*

    *Credit cards will have a processing fee

    If you have Insurance: The percentage of coverage by your insurance company may be based on your insurance company’s own reduced fee schedule for medical services and may be less than actual charges resulting in lower coverage for you. Kevin J. Powers, DPM has no control over this situation. Lower payment is a direct result of the plan selected by you or your employer. Please be advised that we cannot waive co-payment. We are required by law to collect co-payment.

    Commercial Insurance: We will submit your claim to your insurance carrier for you. You are responsible for any deductible or co-payment not covered by your insurance. Once our office has received payment from the insurance company, you will be billed, with 30 day terms, for any amount still owed.

    Medicare: This office accepts Medicare assignment. Medicare patients are fully responsible, however, for the initial yearly deductible and the 20% co-insurance. Federal law requires that physicians collect this amount. If you have a secondary insurance to cover the 20%, we will submit the balance to that insurance for payment and you will only be responsible for the yearly deductible.

    Please sign with your initials (*)

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