Ortho News

Brought To Their Knees
New routes for relief ; Injections 'a miracle' for longtime jock
Knee, Hip Replacement
Patients Recover Faster With Minimally Invasive Surgery

 

Online Registration

 Back
Patient Name:
Last Name: First Name: Middle
 
Personal Information:
Marital Status:
Sex:
Birthdate:
Age:
Social Security #
Home Address:
(Please Do Not Give P.O. Box As Address) City State ZIP Code      
Home Phone: ( )
Work Phone:  ( )
e-mail
Employer:
Parent Or Guardian If Patient Is Minor:
Referring Physician:
How Did You Hear About Us?
Emergency Contact Person: Phone ( )
 
Spousal information
Spouse's Name
Spouse's Work Phone ( )
Spouse's Employer:
Allergies:
 
Primary Insurance Information
Primary Insurance Company:
Address On Card:
Telephone # On Insurance Card:( )
Insured Party: Relationship to Patient:
Insured Party's Sex: Insured Party's Birthdate:
Insured Social Security # Policy Group #
 
Secondary Insurance Information
Secondary Insurance Compan:
Address On Card:
Telephone # On Insurance Card: ( )
Insured Party: Relationship To Patient:
Insured Party's Sex: Insured Party's Birthdate:
Insured Social Security # Policy Group #
 
Medical Issues
Description of Onset/Injury Date of Injury
How Where
Is this covered under workmen's compensation? Yes No      Date of Injury
Have you contacted your employer? Yes No
 
Responsible party
Responsible party's name:
Address
Telephone # ( )
 
Injury Questionaire
Is this injury due to an auto accident? Yes No      Date of Injury
Have you contacted your Insurance Company regarding this accident? Yes No
Auto Insurance Company Responsible:
Address
Telephone # of Claims Examiner ( )
Policy # Claim #
Insured Party Date of Birth
Insured Party's Address
Is this injury due to a third party liability?
Yes No      Date of Injury
Do you have legal representation for this treatment?
Yes No  Attorney's Name
Attorney's Address
Attorney's Telephone # ( )
 
AUTHORIZATION: I hereby authorize Orthopedic Specialists. S.C. to release any information contained in my medical record to my insurance company, referring physician, and/or primary care doctor. I also hereby authorize for benefits to be paid directly to Orthopedic Specialists, S.C. for medical services I receive from any of the physicians in this practice. I understand that I will be responsible for any unpaid balance, including charges for which a referral was not obtained.
 

Date
(note that the exact time the form is received depends upon network latency)

Signature of patient or authorized representative
(will be required at Doctor's office before this authorization is effective)