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PATIENT REGISTRATION FORMToday’s Date:PATIENT INFORMATIONLast Name:First:DOB:Race:Age: African AmericanMi. Init:SSN:Gen: M F American Indian AsianAddress: CaucasianMarital Status: S M D W HispanicCity:Preferred phone #: Pacific IslanderState: OtherZip:Secondary Phone #:select: CELL HOME WORKselect: CELL HOMEState:Zip: WORKEmail address:Occupation:Employer:Employer Address:City:Employer Contact Person:Phone #:EMERGENCY CONTACTName:Relationship to patient:Preferred phone #:Secondary phone #:select: CELL HOME WORKselect: CELL HOMEVISIT INFORMATIONReason for appointment:Date symptoms began:Primary Care Physician:City:Referring Physician (if other than PCP):City:Preferred Pharmacy:City:Phone #:HEALTH INSURANCEPrimary Insurance:Who is the insurance policy holder?Policy #: Self Spouse ParentIf not “self” Policy Holder’s Name:Group ID #: OtherDOB:Policy Holder’s Employer:Employer Phone #:Employer Address:City:Secondary Insurance:Who is the insurance policy holder?SSN:State:Policy #: Self Spouse ParentIf not “self” Policy Holder’s Name:Group ID #: OtherDOB:Updated 8/2018SSN:Zip: WORK
GUARANTOR/LEGAL GUARDIAN (if applicable) Parent Legal Guardian OtherSSN:Name:DOB:Relationship to patient:Address:Phone #:City:State:Zip:WORKERS’ COMP INFORMATION (if applicable)Is this a work-related injury? YES NODid you report it? YES NODate/Time of injury:Did your employer approve this visit? YES NOPart of body injured:Contact person at place of employment:Date last worked:Workers’ Compensation Carrier:Claim #:Address:City:Adjuster’s Name:State:Zip:Phone #:ACCIDENT/PERSONAL INJURY INFORMATION (if applicable)Is this a motor vehicle/personal injury? YES NOInsurance Carrier:Date/time of accident:State accident occurred:Claim #:Address:Phone #:City:State:Zip:State:Zip:ATTORNEY INFORMATION (if applicable)Attorney’s name:Address:Phone #:City:HOW DID YOU LEARN ABOUT PARKVIEW? (Please be specific.) Family/Friend Physician (who?): Have been our patient in the past Hospital or Urgent Care (which one?): Internet search Coach/Trainer (who?): Facebook Health Fair (where/when?): Insurance Company Physician lecture (where/when?): Workers’ Comp case manager or attorney Other (specify):All of the information provided is complete and accurate to the best of my knowledge.PATIENT SIGNATUREDATEYOUR PHOTO ID, INSURANCE CARD, AND COPAY ARE REQUIRED AT THE TIME OF THE VISIT. IF YOU DO NOT HAVE YOURINSURANCE CARD AVAILABLE, ALL CHARGES WILL BE YOUR RESPONSIBILITY AND PAYABLE AT THE TIME OF SERVICE. OBTAININGANY REQUIRED REFERRAL FORMS IS YOUR RESPONSIBILITY, AS ARE ALL UNPAID BALANCES AND/OR DENIED CLAIMS.
PATIENT MEDICAL HISTORYToday’s Date:NameDate of BirthIf you are currently under the care of another physician, please provide his/her name and specialty:PHYSICIANSPECIALTY (What do you see him/her for?)Please list any medications/drugs you are currently taking. (Include any over-the-counter medicine, vitamins, etc.)NAME OF MEDICINEDOSAGETIMES PER DAYPlease list ALL allergies you have. (Including medications, environmental allergies, etc.)Please check any of the following conditions for which you have ever been treated: Tumor or cancer Tuberculosis Blood disease or anemia Convulsions Pneumonia Liver disease Nervous disorder Chest pain Kidney trouble Asthma Back pain/disorder Foot trouble Blood clots Disabling headaches Coughing up blood Rectal bleeding Diabetes Rheumatic fever Broken bone Muscle weakness Fainting spells Polio Stomach trouble or ulcers Goiter or thyroid trouble Blood pressure trouble Dislocation Albumen or sugar in urine Paralysis Shortness of breath Gallbladder trouble Skin rash Heart murmur Blood in urine Heart trouble Arthritis Calf painDETAILS of any conditions that you selected above:
Please list all previous surgeries, including the year and the name of your physician:SURGERYYEARNAME OF PHYSICIANSOCIAL HISTORYDo you smoke tobacco? Never smoker Current every day smoker Former smoker Current occasional smokerDo you consume alcohol? YES NODo you use recreational drugs? YESYears smoked:Packs per day:If yes, approximate number of drinks per week: NOPlease list any additional information that you feel is important for your doctor to know:Patient Signature:Date:
PATIENT AGREEMENTS ANDAUTHORIZATIONSCONSENT FOR TREATMENT. I hereby consent to the treatment provided by Parkview Orthopaedic Group (the Practice) and itsemployees or designees. I authorize the mental and physical health care services deemed necessary or advisable by my caregivers toaddress my needs.INITIAL:AUTHORIZATION FOR RELEASE OF PERSONAL HEALTH INFORMATION (PHI). I authorize use and disclosure of my PHI for thepurposes of diagnosing or providing treatment to me, obtaining payment for my care, or for the purposes of conducting thehealthcare operations of the Practice. I authorize the Practice to release any information required in the process of applications forfinancial coverage for the services rendered. The Practice may release objective clinical information related to my diagnoses andtreatment, which may be requested by my insurance company or its designated agent.INITIAL:I authorize the Practice to release information about my medical condition to the following :PATIENT COMMUNICATIONS. I consent to be contacted by the Practice or anyone calling on its behalf for any reason, includingappointment reminders and past due patient balances. I authorize the Practice to contact me at any telephone number or physicalor electronic address I provide. I agree that the Practice may contact me in any way, including calls or text messages delivered by anautomatic telephone dialing system, or email messages delivered by an automatic emailing system. I agree to promptly notify thePractice at any time my contact information changes.INITIAL:CANCELLATION/NO-SHOW POLICY: I understand that the Practice requires a 24-hour advance notification for the cancellation of ascheduled appointment for a physician, physical therapy, x-ray, MRI, etc. This allows the Practice to accommodate other patientsseeking appointments. I understand that if I cancel an appointment without 24-hour notice, or fail to show for my scheduledappointment, I will be subject to a fee of 50.00. I know that my physician has no discretion regarding the matter. INITIAL:ASSIGNMENT OF INSURANCE BENEFITS/PAYMENT GUARANTEE/COLLECTION FEE. I authorize payment to be made directly to thePractice for insurance benefits payable to me. I understand that I am financially responsible to the Practice for any covered or noncovered services, as defined by my insurer. I understand that if my account balance becomes overdue and the overdue account isreferred to a collection agency, I will be responsible for the costs of collection including reasonable attorney’s fees. INITIAL:PRIVACY POLICY. I acknowledge having received the Practice’s “Notice of Privacy Practices.” My rights, including the rights to seeand copy my record, to limit disclosure of my health information, and to request an amendment to my record, are explained in thePolicy. I understand that I may revoke in writing my consent for release of my health care information, except to the extent thepractice has already made disclosures with my prior consent.INITIAL:PRINT NAME (Patient or Authorized Person who is signing consent)Signature:RELATIONSHIP (if not patient)Date:If patient is unable to sign, verbal consent may be given. Reason:Witness Signature:Date:Updated 8/2018
PATIENT AGREEMENTS AND AUTHORIZATIONS CONSENT FOR TREATMENT. I hereby consent to the treatment provided by Parkview Orthopaedic Group (the Practice) and its employees or designees. I authorize the mental and physical health care services deemed necessary or advisable by my caregivers to
