Patient Intake Form Orthopedic Specialty Institute

 

 

Patient Intake Form

 

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Today’s   D ate:   _ __________________  

Name:    

    Birth   D ate:    

   

 

Spouse:   _ __________________________________________     B irth   D ate:____________________________  

Guarantor   I nfo   i f   u nder   1 8:   _ _________________________________________________________________  

SS   # :    

 

        A ge:                                     G ender:     M   /   F         E mail:                                                                      

 

Address:    

 

Phone:      

   

   

 

 

  ( home)  

(work)  

(cell)  

Marital   S tatus:  

Single  

Married  

Divorced/Separated    

Widowed  

Preferred   L anguage:     □ English   □ Other:____________________    

Race:       □ American   I ndian   □ Asian   □ Black/African   A merican   □ Japanese   □ White   □ Other:__________   □ Declined  

Ethnicity:     □ Central   A merican   □ Hispanic   o r   L atino/Spanish   □ Not   H ispanic   o r   L atino   □ Other:______   □ Declined  

 

Employer   N ame   &   A ddress:                                                                                                                                                                                                                                                                                                    

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Primary   I nsurance   C overage:  

 

 

 

 

 

 

 

(Name   o f   C arrier)  

 

 

(Policy   N umber)  

 

 

(Group   N umber)  

 

 

 

 

 

 

 

(Subscribers   N ame   &   R elationship   t o   p atient)  

 

 

(Subscriber   D OB)  

 

 

(Insurance   P hone)  

Secondary   I nsurance   C overage:  

 

 

 

 

 

 

 

(Name   o f   C arrier)  

 

 

(Policy   N umber)  

 

 

(Group   N umber)  

 

 

 

 

 

 

 

(Subscribers   N ame   &   R elationship   t o   p atient)  

 

 

(Subscriber   D OB)  

 

 

(Insurance   P hone)

 

1) How   d id   y ou   h ear   a bout   u s   o r   w ho   s ent   y ou   t o   s ee   u s?      

Name    

Phone    

 

 

2) Who   i s   y our   P rimary   C are   P hysician?    

Name    

Phone    

 

City,   S tate,   Z ip    

 

       

                W hat   P harmacy   d o   y ou   u se?  

                N ame   _ __________________________________________________Phone______________________                  

                C ity,   S tate   &   Z ip_______________________________________________________________________  

 

Are you currently taking any narcotics? ____ Yes ____ No What? _____________ How long? ________

I agree that the Orthopedic Specialty Institute may request and use my prescription medication history from other

healthcare providers or third party pharmacy benefit payors for treatment purposes.

Signature of Patient or Patient’s Representative: _____________________________________________

 

3) Please   l ist   a ll   m edications   y ou   c urrently   u se   w ith   d osage   a nd   f requency:    

 

 

 

 

 

Patient   N ame:    

 

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