• New Patient Packet

    Orthopedic Spine

  • New Patient Information

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Race*
  • Ethnicity*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • How did you hear about us?

  • Guarantor

    Person responsible for the bill if the patient is a minor or student:
  • Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Insurance Information

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  • Choose File
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  • Acknowledgement

    I acknowledge that by providing insurance information, I have asked and promise to pay for services provided in exchange for this information. I assign to Midlands Orthopaedics & Neurosurgery, PA all health insurance benefits available for services provided to me. I understand that fees for services provided by Midlands Orthopaedics & Neurosurgery, PA are my responsibility, and I agree to pay any balance left unpaid by any insurance company or third party entity immediately upon notification of said balance. If I do not have insurance, I understand that I am responsible for any incurred expenses in their entirety.
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • Midlands Orthopedics and Neurosurgery (MON) Authorizations and Acknowledgements

  • 1. NOTICE OF PRIVACY POLICIES: I have been offered a copy of the MON Notice of Privacy Policies detailing how my protected health information (PHI) may be used and disclosed as permitted under federal and state law. I understand that MON is permitted to disclose my PHI without my authorization to facilitate treatment, payment and health care operations. This notice is always available on the MON website (www.midorthoneuro.com) and at each office location upon request.

    2. FINANCIAL POLICY: I have been offered a copy of the MON Financial Policy and acknowledge its requirements. This notice is always available on the MON website (www.midorthoneuro.com) and at each office location upon request.

    3. ePrescribe: I understand that MON utilizes electronic health record software which incorporates ePrescribing technology. I understand that MON may access and use my prescription history through ePrescribing software to facilitate appropriate treatment.

    4. PAPERLESS BILLING: MON delivers paperless billing statements via our patient portal. I understand that I am automatically enrolled to receive paperless billing statements via the email address provided at registration. Changes to statement preferences may be made via the patient portal at any time.

    5. PATIENT PORTAL: The patient portal is the most efficient tool to securely request appointments and communicate with our staff members, allowing you to bypass our phone system completely. Registering by smartphone is fast and easy. Ask the front desk staff to send a text with the registration link. Use the link and temporary password to login. You may also follow the Patient Portal link on our website (www.midorthoneuro.com) and click “Sign Up Today.” You will need to enter your name, date of birth and email address as they appear in your MidOrthoNeuro account.

    I acknowledge understanding of the items described on this Authorizations & Acknowledgements form.

  • Today's Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • HIPAA PRIVACY AUTHORIZATION

    I hereby authorize Midlands Orthopaedics & Neurosurgery, PA, to use and/or disclose the protected health information below to:
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Authorization for Release of Information:

  • Covering the period of healthcare from:
     - -
    2 digit month, 2 digit day, 4 digit year
  • To:
     - -
    2 digit month, 2 digit day, 4 digit year
  • -Covering the following protected health information:
    • I understand that I have the right to revoke this authorization, in writing, at any time.
    • I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.
    • I understand that my treatment, payment, enrollment or eligibility for benefits will not be conditioned upon signing this authorization.
    • I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.
  • Today's Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • General Medical Information

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Family History (Please check any that have occurred with blood relatives)

  • Social History

  • Are you a:
  • If current smoker, how often do you smoke cigarettes?
  • If current smoker, how much do you smoke per day?
  • Cigar/Pipe Use*
  • Alcohol Use*
  • Marital Status:
  • Diet*
  • Work History
  • Are you currently employed?*
  • Are you currently working?*

  • Past Medical History

  • Check any past/current patient problems:

  • History of Present Illness

    Please select all that apply.
  • Location
  • Type of pain:
  • Severity
  • Date of Onset
     - -
    2 digit month, 2 digit day, 4 digit year
  • Timing
  • How did the injury occur?
  • What helps ease the pain/discomfort:
  • Describe the pain/discomfort:
  • If yes, date:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Prior Imaging:
  • Previous Injections:
  • Previous Physical Therapy:
  • Working
  • Type of pain (select all that apply):
  • Does this pain interfere with any of the following activities of daily living? (Select all that apply)
  • How often are you having pain?
  • In the past 6 months, have you received any formal therapy for this condition?
  • Do you perform home exercises/stretches for this condition?
  • Have you received an Epidural Steroid Injection for this condition?
  • Have you tried any of the follwing for pain relief? (Select all that apply)
  • Are you claustrophobic (fear of being in a closed/confined place)?
  • Do you have metal in your body?

  • How has back pain impacted your daily life?

    Select one statement in each section that most accurately describes your pain.
  • Pain Intensity
  • Personal Care: Washing, Dressing, Etc.
  • Lifting
  • Walking
  • Sitting
  • Standing
  • Sleeping
  • Sex Life
  • Social Life
  • Traveling
  • Should be Empty: