Patient Registration

  • Patient Registration

  • Date of Birth / Fecha de Nacimiento*
     - -
  • Gender / Género*
  • Format: (000) 000-0000.

  • Work Comp Claim Information

    Información sobre reclamaciones de indemnización laboral
  • Date of Injury / Fecha de la lesión:*
     - -
  • Have you injured this body part/s before / ¿Se ha lesionado esta parte del cuerpo?
  • Have you had an MRI, MRA or CT? If so where?*
  • Format: (000) 000-0000.

  • Medical History

    Historial médico
  • Do you have, or have you ever had problems with the following:

  • Surgical History

  • Have you ever had surgery?

  • Medication and Allergies

  • Are you taking any weight loss medications?*
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  • Are you on a pain contract with another physician

  • Family History

  • Any of your immediate family members have or had any of the following?*

  • Social History

  • Do you smoke tobacco?
  • Do you drink alcohol?
  • Do you use any recreational drugs?
  • Marital Status

  • Review of Systems

    Please mark any of the following you are currently experiencing:
  • General*
  • Heart and Lungs*
  • Nervous System*
  • Stomach and Intestines*
  • Muscle/Joints/Bones*
  • Psychiatric*
  • Skin*
  • Blood*

  • Consent to use or disclose Medical Information  

  •  


    I authorize Occupational Orthopedics, LLC to use and disclose of my health and medical information for the following purposes:

     

    • Treatment: Use by our providers, staff, coordinating care with other medical providers, work compensation carrier and disability insurance companies
    • Payment: Including authorization, scheduling, billing, payment, review for medical necessity, justification of charges, precertification and prior authorizations
    • Healthcare Operation: Includes the usual administrative and business functions of our office

     

    I understand that I have the right to revoke or restrict this consent provided that I do so in writing, except to the extent that Occupational Orthopedics, LLC has already used or disclosed the information in reliance to this consent.

     

  • Date*
     - -
  • Should be Empty: