Scheduler Initials
Scheduled Appointment Date and Time
-
Year
-
Month
Day
Date
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Emory Healthcare Medical Record Number (MRN)
Has the patient been seen at Emory Sports medicine in the past 3 years?
*
YES
NO
Patient’s Full Name
*
First Name
Middle Name
Last Name
Suffix
Patient's Date of Birth
*
Patient's Gender
*
Male
Female
Patient's Address
*
Street Address Line 1
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Is the patient over 18 years of age?
*
YES
NO
Parent/Guardian's Full Legal Name
*
First Name
Middle Name
Last Name
Suffix
Parent/Guardian's Date of Birth
*
Is the Parent/Guardian address different from the patient?
*
YES
NO
Parent/Guardian's Address
Street Address Line 1
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Insurance Holder's Relationship to the Patient
*
Self
Father
Mother
Spouse
Step-father
Step-mother
Guardian
Other
Please upload picture of your insurance card (Front and Back required)
*
Browse Files
Cancel
of
Insurance Subscriber/Member ID Number
*
Name of School or Affiliated Organization
*
Name of Sport
Name of Person Referring the Patient to Emory Sports Medicine
First Name
Last Name
Body Part
*
Side Affected
*
Right
Left
Both
N/A
Brief Description of Injury
*
Will you be bringing any imaging to this appointment? (X-rays, MRI, CT)
*
YES
NO
What imaging will you bring? Please check all that apply.
X-rays
MRI
CT
Other
Requested Doctor
Preferred Day (s) for Appointment
Monday
Tuesday
Wednesday
Thursday
Friday
Any
Preferred Time for the Appointment
Mornings
Afternoons
First Available
How would you like to receive confirmation of the appointment date/time and location?
*
Phone Call
Text Message
E-mail
Other
Enter email address if preferred communication
example@example.com
Submit
Should be Empty: