NEW PATIENT INFORMATION

Denver Osteopathic and Sports Medicine Center

Thank you for choosing our office! In order to serve you properly, we will be needing the following information.
NEW PATIENT INFORMATION
Date*

MonthDayYear
Date
Name*

First NameLast Name
SSN*
00-00-0000
Date of Birth*

MonthDayYear
Birth Date
Primary Phone*
Home/Cell
Email
example@example.com
Referred By:
Emergency Contact*

First NameLast Name
Relationship to Patient*
Emergency Contact Phone*
Responsible Party and Insurance Information
Responsible Party*
Name
Relationship To Patient*
DOB of Policyholder (if other than self)

MonthDayYear
Date
Home phone*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Company*
Group #*
Policy #*
Secondary Insurance (if any) (include group & policy #)
Is this person currently a patient of DOSMC?

YesNo
Phone/Message Consent
By signing below, I give permission to DOSMC (its providers, admin and billing staff) permission to contact me via phone regarding lab results, imaging results, answers to questions I may have, and billing information.
Signature*

Clear
Date*

MonthDayYear
Date
FINANCIAL / BILLING POLICIES
Co-pays are due at time of visit. It is your responsibility to be aware of any limit on the # of osteopathic treatments your insurance will cover. If you do not have insurance, you will be expected to pay your balance in full at the time of your visit unless you have a signed payment agreement. Denver Osteopathic and Sports Medicine Center is NOT a participating MEDICAID, Kaiser Permanente or-as of Spring 2023-Tricare or OptumCare provider. Any Medicaid, Kaiser, Tricare, or OptumCare balance will be considered patient responsibility and billed at the self-pay rate.

If at any time a patient balance is accrued, you will be sent a monthly statement from our office. Payment is to be made in full at that time or, if needed, you may contact us to set up a payment agreement. If the patient balance remains unpaid after 90 days, you will be sent a late notice with a collections submission date. If/when all attempts fail and payment is not made in a timely manner, we reserve the right to send your account to collections. You will be responsible for any additional collection agency fees and/or charges incurred, including reasonable attorney costs, if applicable.
Patient Initials
I have read and understand the above information:*

Clear
Date*

MonthDayYear
Date
Name*

First NameLast Name
Consent for Use and Disclosure of Personal Health Information
This form authorizes us to use and disclose your protected health information (PHI) for purposes of healthcare operations, treatment, and payment activities.

Before signing, please read our notice of Privacy Policies to gain a clear understanding of how we may use and disclose your PHI.

For questions concerning our Notice of Privacy Policies, please contact our office at (303) 991-4651.
Patient's Consent
Name*

First NameLast Name
Telephone*
Address*
City*
State*
Zip*
I have read DOSMC's Notice of Privacy Policies and I consent to its use of my PHI for the purposes of healthcare operations, treatment, and payment activities.
Signature*

Clear
*If this consent is signed by a parent or guardian on behalf of the patient, please complete the following:
Parent or Guardian Name
Relationship to Patient
NEW PATIENT - PHYSICAL/MEDICAL HISTORY
Name*

First NameLast Name
Date*

MonthDayYear
Date
Gender

MaleFemaleOther
Date of Birth*

MonthDayYear
Date
Marital Status

SingleMarriedDivorcedPrefer not to answer
Age*
Main Concern(s)
FAMILY HISTORY
If any blood relative has suffered any of the following, please check-mark the corresponding box:

EPILEPSYTHYROIDOSTEOPOROSISMIGRAINEARTHRITISALCOHOLISMMENTAL ILLNESSASTHMAHAYFEVERHEART DISEASECANCERGLAUCOMAANEMIASTROKEDIABETESBLEEDS EASILYHYPERTENSION
HOSPITAL ADMISSIONS/SURGERIES

(not including pregnancies)
ILLNESS/OPERATION & YEAR
ILLNESS/OPERATION & YEAR
ILLNESS/OPERATION & YEAR
LIST ALL MEDICATIONS YOU ARE CURRENTLY TAKING
MEDICATIONS (including non-prescription, vitamins, and dietary supplements)*
LIST ANY & ALL ALLERGIES TO MEDICATION
ALLERGIES
VACCINATIONS

(Please only check-mark COVID-19 box if you have been FULLY vaccinated)
VACCINES*

COVID-19FLUPNEUMONIASHINGLESTETANUSOther
SOCIAL HISTORY
ALCOHOLCAFFEINE (Coffee, Tea, Soda)TOBACCO (Cigarettes, Chewing Tobacco, Cigars)MARIJUANAILLICIT DRUG USE (Amphetamines, Cocaine, Heroin)Other
PLEASE LIST ALL OTHER PHYSICIANS YOU ARE ESTABLISHED WITH:

Please include name, specialty, and what treatment you are receiving
List of physicians:
Do you exercise regularly?*

YesNoOther
Are there any problems or concerns we should be aware of?*
Name of pharmacy to send medications to (if needed):*
Address of pharmacy:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Pharmacy Phone Number*
Please enter a valid phone number.
How do you prefer we contact you with any results?*
May we leave a detailed message for you?*

YesNo
May we leave a detailed message with someone else?*

YesNo
If so, with whom?
Should be Empty:

Denver Osteopathic and Sports Medicine Center

NEW PATIENT INFORMATION

Responsible Party and Insurance Information

Phone/Message Consent

FINANCIAL / BILLING POLICIES

Consent for Use and Disclosure of Personal Health Information

Patient's Consent

NEW PATIENT - PHYSICAL/MEDICAL HISTORY

FAMILY HISTORY

HOSPITAL ADMISSIONS/SURGERIES

LIST ALL MEDICATIONS YOU ARE CURRENTLY TAKING

LIST ANY & ALL ALLERGIES TO MEDICATION

VACCINATIONS

SOCIAL HISTORY

PLEASE LIST ALL OTHER PHYSICIANS YOU ARE ESTABLISHED WITH: