New Patient Forms for San Francisco House Calls - DOC

New Patient Forms for San Francisco House Calls

Welcome to the download center. Here you can download all new patient form, policies, and brochures regarding foot and ankle conditions and treatments.  

In order to expedite your visit, please feel free to download the following forms. If you complete these forms and fax them to us prior to your initial house call visit in San Francisco, the physician will have more information about your condition.  This will save you time.  If you keep the completed form with you Dr. Segler will review it and discuss with you at the time of your House Call visit. The completed forms can be faxed to us or scanned and emailed to

Forms for new patients:

If you have never been seen by Doc On The Run San Francisco Podiatry House Calls, you will want to complete the first two forms below. Completing these before your visit will save time during your appointment.  


Medical History Form  

The Medical History form will give the doctor some background about your past medical history and current foot and/or ankle complaint that needs to be treated. 

New Patient Medical History form in PDF format


Privacy Policy (HIPPA) Form  

The HIPPA policy explains the way we will use and protect your sensitive health care information. For simplicity you can review the short form. Once you have read the policy, please sign and date the last page. We will need to have written verification that you have reviewed the policy before the doctor can see you. If you think it is best to read the unabridged version of the HIPPA policy, you can print and read the “long form.”  In either event, we need to have a signed copy of the last page of one of these two HIPPA policy forms on or before the day of your house call visit by the podiatrist in San Francisco. 

HIPPA policy (short form) in printable PDF format

HIPPA policy (long form) in printable PDF format 


Medicare Opt-Out Agreement Form  

In order to provide the highest level of service without the constraints and bureaucratic rules of Medicare, Dr. Segler opted-out of Medicare several years ago. We will not bill Medicare for your visit or treatment. Our patients are not permitted to bill Medicare for services provided by any provider who has chosen to opt-out of Medicare. In fact, if you have Medicare, you read and sign the Medicare Opt-Out Agreement at your initial visit and then at each renewal period.  

Medicare Opt-Out Agreement form in printable PDF format


Medical Record Release form in printable PDF format  

We believe in your right to privacy. We will never, ever release your protected information without your express written consent.  If you would like to have us send any of your medical records to an insurance company, another provider or even directly to you, you must complete this form, have it it witnessed and return the competed form directly to us.  

Medical Record Release form in printable PDF format 

Surgical Second Opinion form in printable PDF format  

If you have already had bunion surgery by another doctor and would like to be seen for an evaluation, you must complete the Surgical Second Opinion Evaluation Application. The goal is to make sure that if you are traveling from out of state or from overseas to see Dr. Segler, we want to make sure that he will accept your case and that he will be able to help you with reconstructive foot surgery or with other advanced treatment options.  

Surgical Second Opinion Evaluation form


Printable Patient Education Handouts

Not everyone needs to see a podiatrist or foot surgeon.  We have site visits from people all over the United States who come to our website in search of the best treatment information about foot and ankle conditions. If you would like more information on the most commonly treated sources of foot pain, feel free to print any of the brochures below. They are all in printable PDF format.  

Achilles Tendon Pain

Bunion Pain

Custom Orthotics 

Gout Diet Instructions   

Gout Medication Instructions 

Heel Pain/Plantar Fasciitis Treatment Instructions  

Running Shoe Recommendations by San Francisco Running Podiatrist