• Vallejo: (707) 644-4049
  • Napa: (707) 259-0766

New Patient Insurance Information

New Patient Insurance Information

Responsible Party for Insurance Billing and Services:

First Name (required)

Middle Name

Last Name (required)

Email Address (required)


Relationship to Patient

Emergency Contact Name

Emergency Contact Telephone

Emergency Contact Relationship to Patient

Insurance Name

Name of Insured if Not Patient

Subscriber/Insured Party Date Of Birth

Subscriber/Member Number

Secondary Insurance

Name of Insured

Subscriber/Member Number

Subscriber Date of Birth

All professional services rendered are charged to the patient. Necessary forms will be completed to help expedite insurance coverage. It is also customary to pay for services when rendered unless other arrangements have been made with our office.

Insurance authorization and assignment:

I hereby authorize Napa Solano Foot and Ankle to furnish information to insurance carriers concerning my illnesses and treatments and to my referring physician if so requested. I hereby assign to the physician all payments for my medical services rendered to myself or my dependents. I understand that I am responsible for any amount not covered by my insurance.

 Yes No

May we use photographs taken of your feet for educational purposes only?

 Yes No