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Patient Intake Form

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Contact Information


Contact Information

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Emergency Contact


Emergency Contact

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Insurance Information


Insurance Information

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Spouse Information


Spouse Information

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Primary Care Physician Information


Primary Care Physician Information

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Referring Physician Information


Referring Physician Information

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Workers Compensation and Auto


Workers Compensation and Auto

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Pain Management


Pain Management

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For Minors / Legal Guardian


For Minors / Legal Guardian

PLEASE FILL THIS PORTION OUT IF PATIENT IS A MINOR OR HAS A LEGAL GUARDIAN:

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Pharmacy Information


Pharmacy Information

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Medications


Medications

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Allergies


Allergies

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Family History


Family History

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Medical Problems/ History


Medical Problems/ History

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Social History


Social History

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Do you live in a:

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Surgical History


Surgical History

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Injury Information/ Reason for Today’s Visit


Injury Information/ Reason for Today’s Visit

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Musculoskeletal Review of Symptoms


Musculoskeletal Review of Symptoms

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Current Medical Status


Current Medical Status

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Body Parts Involved


Body Parts Involved

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Which of the following, if any, makes symptoms worse?

Do you have any of the following?

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Previous treatment for this problem?

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Consent to Treatment and Payment Authorization


Consent to Treatment and Payment Authorization

I hereby give my consent to the physicians and other clinical personnel of for Sports Medicine & Joint Replacement Specialists, Corp. for the evaluation and treatment of the conditions for which I present in their offices.

I hereby authorize the office of Sports Medicine & Joint Replacement Specialists, Corp. to release any medical information required to permit payment directly to them for services rendered.

I authorize Sports Medicine & Joint Replacement Specialists, Corp. to release information related to my condition to the applicable worker's compensation carrier, auto insurance carrier, or my personal health insurance carriers as necessary based on the type and place of injury.

I recognize and accept the responsibility for services rendered regardless of insurance coverage; including but is not limited to, co-insurance, co-payment, deductible, and non-covered services.

Sports Medicine & Joint Replacement Specialists Corp. will not accept any attorney's letter of protection. All charges for my care are ultimately my responsibility to pay in full, within 60 days of services rendered.

Patient Consent for Use and Disclosure of Protected Health Information


Patient Consent for Use and Disclosure of Protected Health Information

Our Notice of Privacy Practices provides information about how we may use or disclose protected health information. The notice contains a patient’s rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent.
The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date.
You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement.
The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations. By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication.
You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive.

By signing this form, I understand that:

  • Protected health information may be disclosed or used for treatment, payment, or healthcare operations.
  • The practice reserves the right to change the privacy policy as allowed by law.
  • The practice has the right to restrict the use of the information, but the practice does not have to agree to those restrictions.
  • The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.
  • The practice may condition receipt of treatment upon execution of this consent. 
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Please sign your name in the area below

By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

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