OrthoLive VUC Form

Medical Emergencies should Call 911 or visit the nearest Emergency Room

Have you recently seen an Orthopedic Provider regarding this injury?*

YesNo

Due to this being an existing injury and you have already received medical care, please contact your existing provider for additional treatment and information.

Patient Information

Name*

First NameLast Name

Email*

example@example.com

Mobile / Cell Number*

Area CodePhone Number

Date of Birth*

Date

What is your primary/preferred language?*

Consent for Treatment of a Minor

(Hereinafter “I”) seek the healthcare related services of OrthoLive Medical Group (“Practice”) for myself, my child, or otherwise an individual over whom I am empowered to provide such authorization, and I hereby voluntarily consent to the provider (“Provider”) and/or any other healthcare providers and staff associated with Practice to provide me/my child/minor with healthcare related advice, basic treatments, medical and/or diagnostic procedures. I hereby consent to their participation in the care and treatment of me/my child and the sharing of their information upon any referral to another healthcare provider. I am here for my own purposes and not on behalf of any third-party. I understand that I am a participant in the decision-making process, and I am free to decline advice, services, or treatments at any time. I agree to bring to the attention of Practice’s clinical staff, if, at any time, I have any lack of understanding of such risks, benefits, and alternatives, and inquire of clinical staff for further explanation until I have a full understanding before giving consent to any procedure or treatment. I acknowledge that some or all of the healthcare professionals performing services for the Practice are independent contractors and are not agents or employees.

Guardian Name

First NameLast Name

Guardian Email

example@example.com

Guardian Mobile / Cell Number

Area CodePhone Number

Home Address*

Street Address

Street Address Line 2

CityState

Zip Code

Current Location (Complete if different from Home Address)

Street Address

Street Address Line 2

CityState

Zip Code

Injury Information

How urgent is your injury? (1 = Not Urgent | 2 = Urgent | 3 = Medical Emergency)*

	1	2	3

1 is Not Urgent, 3 is Emergency

If exact Injury Date is unknown, estimate how long you have been dealing with the injury and select a date around that time.

Injury Date*

Did this injury happen at work?*

NoYes

Name of your Employer

Body Part*

Side of Body*

Chief Complaint*

Injury Description:*

Please describe your injury, how it happened, pain level, and so on. The more information you can provide the better our treatment.

How is the pain feeling? (1 = Better | 2 = Steady | 3 = Getting Worse)*

	1	2	3

1 is Better, 3 is Getting Worse

What is the pain level? (1 = Low | 5 = Moderate | 10 = High) *

	1	2	3	4	5	6	7	8	9	10

1 is Low Pain, 10 is High Pain

Current Treatment

Please describe any treatment you are doing currently.

You may upload images of the injured body part below.

Pictures or Images of Injured Body Part

Browse Files

Would you like to have an immediate Virtual Visit, Chat with a Licensed Orthopedic Triage Specialist (ATC) by Text, or be referred to a Practice?*

Virtual VisitChat with a Specialist by TextRefer to Practice

Insurance Information

Insurance Type

Insurance Carrier / PayerSelf-pay

Carrier Name

Group Number

Policy / Member Number

Payment

All visits are in English. If translation/interpreter is required, select appropriate service and indicate your primary language.

Are Translation Services Required?*

NoYes

Please select services below: *

Injury Triage Telehealth Visit$25.00

Virtual Visit

Translation Service$25.00

Translation Services

Total $0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Billing Address (If different from Home Address)

Street Address

Street Address Line 2

CityState

Zip Code

Preferred Date and Time of Appointment

Practice

Today

Date

MinorDOB

Date

Complete the information below to schedule a Virtual Visit.

We will send you a text from the number below to start chatting with our Team.

We will send you an email and text of the nearest Medical Practice.