Orthopedic & Sports Medicine Center

Please complete this entire form prior to your appointment.

Full Name *

Date of Birth *

Which Doctor are you seeing? *

Appointment Date *

Reason For Your Appointment

Is this the result of an injury?*

Work

Auto

Other

If Yes, Who/When?

Sex*

Male

Female

E-mail Address *

Cell Phone Number

Phone Number *

Work Phone Number

Street Address

City

Employer

Emergency Contact *

Postal / Zip Code

Occupation

Emergency Contact Phone Number *

How did you hear about our office?

Back Next

Guarantor (Person responsible for payment) *

Primary Insurance Name

Primary Insurance Company

Primary Insurance ID Number

Primary Insurance Date of Birth

Primary Insurance Group Number

Secondary Insurance Name

Secondary Insurance Company

Secondary Insurance ID Number

Secondary Insurance Name Date of Birth

Secondary Insurance Group Number

Medicaid ID Number (If applicable)

Accept Terms *

I authorize the medical to release any information, including diagnosis, treatment plans/records and radiographs to third party payers and/or health practitioners. I authorize and request that my insurance company (if applicable) pay directly to the medical group or medical benefits that are, otherwise, payable to me. I understand that my medical insurance may pay less than the actual bill for service or may not cover certain treatment.

I hereby certify that the foregoing information is accurate and complete and that in consideration of treatment and services rendered to me or my dependents by this medical office, I accept responsibility and agree to be obligated to pay the office in accordance with its payment and credit terms and policies.

Submit

Back Next

Patient Registration

Please complete this entire form prior to your appointment.

Orthopedic & Sports Medicine Center

Office Hours: