New Patient Check In
Pacific Crest Orthopedics
Legal Name
*
First Name
Middle Name
Last Name
Suffix
Preferred Name
If you have a name you go by other than your legal name above, please tell us here.
Please upload a photo of yourself
*
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Social Security Number (optional)
We sometimes use SSN as an identifier when communicating with insurance companies.
Preferred Gender Pronouns
*
She/her
He/him
They/them
Other
Gender
*
Female
Male
Non-binary
Other
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Emergency Contact Name
*
Emergency Contact Relation
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Where did you find us?
*
Please Select
Google
Yelp
Zocdoc
Word of Mouth
Doctor's Office
General Urgent Care
Physical Therapist
Insurance Company Website
Social Media
Walked by our Office
Existing Patient
GGTC
High School Sports
Other
Who referred you?
Who is your primary care physician?
Reason for Visit
*
Note: due to time constraints, we only assess/treat one body part per visit.
Side
*
Left
Right
Both
Date of Injury
*
Current Medications
May we look up your medication history?
*
Yes
No
Allergies to Medications
Past Medical History
*
None
Bleeding Disorders
Blood Clots
Heart Attack (MI)
Heart Failure (CHF)
Cancer
Diabetes
Epilepsy/Seizures
High Blood Pressure (Hypertension)
High Cholesterol
Stroke
Asthma
COPD
Osteoporosis
Osteoarthritis
Thyroid Disease
Kidney Disease
Liver Disease
Autoimmune Disorders
Acid Reflux (Heart Burn)
Migraine Headaches
Psychiatric Disease
Alcoholism
Drug Abuse
Other
Past Surgical History
*
Preferred Pharmacy
*
If you do not enter a pharmacy, we will default to sending any prescriptions to the closest pharmacy to our office.
Pharmacy Address or Cross Street
*
Responsible Party for Patients Under Age 18
Whom shall we contact for billing inquiries?
Responsible Party (Parent/Guardian) Name
First Name
Middle Name
Last Name
Suffix
Responsible Party Relationship to Patient
Responsible Party Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Responsible Party Email
example@example.com
Consent Forms and Agreements
HIPAA Data Use Agreement
HIPAA Data Use Agreement Acknowledgement
*
I have read and agree to the HIPAA Data Use Agreement.
Online Communication Agreement
Online Communication Agreement Acknowledgement
*
I have read and agree to the Online Communication Agreement.
Credit Card on File Agreement
Credit Card on File Agreement Acknowledgement
*
I have read and agree to the Credit Card on File Agreement. I agree to allow Pacific Crest Orthopedics to charge my card on file for any balance due up to a maximum of $500 every 2 weeks.
Consent to Medical Documentation Service
Consent to Medical Documentation Service
*
I have read and agree to the Patient Consent to Medical Documentation Service Agreement.
Cancellation Policy
48 Hour Cancellation Policy
*
I agree to Pacific Crest Orthopedics's cancellation policy and understand that I will be charged a $75 late cancellation fee if I do not cancel at least 48 hours in advance of my appointment.
Signature - I have read and agree to the HIPAA Data Use Agreement, the Online Communication Agreement, the Credit Card on File Agreement, and the Cancellation Policy:
*
Insurance Information
Insurance Card Front
Insurance Card Back
Are you the primary subscriber on your insurance plan?
Yes
No
Primary Subscriber's Legal Name
First Name
Last Name
Primary Subscriber's Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Submit
Should be Empty: