Patient Information

Patient Information

Olympic Sports & Spine has received a referral from you doctor requesting our services. Please take a moment to fill out this information form. It will help us complete your registration and allow us to get you scheduled as soon as possible.
Have you been seen at Olympic Sports & Spine before?*

NoYes
Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Date
Sex Assigned at Birth
Pronouns

He/Him/HersShe/Her/HersThey/Them/TheirsZe/Zir/ZirsEy/Em/EirsOther
Email*

Confirmation Emailexample@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
SMS/Text Message Consent

Yes! Please text me at the phone number above.No! Do not text me.
By selecting yes, you agree to receive automated text messages from Olympic Sports & Spine, PLLC. Consent is not a condition for being a customer. Reply 'HELP' for help or 'STOP' to cancel. Message and data rates may apply. View our SMS Terms and Privacy Policy.
When is the best time to contact you?

AnytimeMornings (8am - 11am)Mid Day (11am - 1pm)Afternoon (1pm - 5pm)Other
Are either of these true?*

My injury is related to a Motor Vehicle Accident (MVA)My injury is related to a on the job injury (L&I)Neither of these are true
What is your claim number?*
Insurance Information

Please upload a copy of the front and back of your insurance card(s). By providing this information, our team is able to begin verifying your covered benefits.
How would you like to upload your insurance card?

Take a picture with my cameraUpload existing imageI do not have my insurance card with me
That's ok, we understand. Our team will still be able to process your information. Please bring a copy of your insurance card to your first appointment. If you have access to your insurance information, you can type if in below. Otherwise, please leave this information blank and our team will collect this information later.
Insurance Company Name
Name on Insurance Card
Insurance Policy Number
Insurance Group/Plan Number
Insurance Card File Upload (Front and Back)

Please upload a copy of the front and back of your insurance card. By providing this information, our team is able to begin verifying your covered benefits.
Cancelof
Insurance Card (Front)
Insurance Card (Back)
Press submit to complete your form. OSS will use the information provided to update your registration and begin verifying your insurance coverage. Once this process is complete, we will reach out to you to schedule your appointment.

If you have any questions please contact us at (253) 201-6022 or scheduling@osstherapy.com
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Patient Information

Insurance Information