Appointments: 973.751.0111
Tweet
Joint Replacement
Sports Medicine
Foot and Ankle
Femino-Ducey-queler
Registration cannot be completed using your mobile device
Orthopaedic group
Patient Information
Last Name:
*
First Name:
*
Date of Birth:
*
Sex:
Male
Female
*
Marital Status:
Select
Single
Married
Widow
Divorced
*
Social Security:
Home Address:
*
Floor/Apt/Suite:
City:
*
State:
*
Zip:
*
Home Phone:
*
Cell:
Race:
Employer:
Work Phone:
*
Employer Address:
Floor/Suite:
City:
State:
Zip:
Referred by:
Primary Care Dr:
*
Phone:
*
Address:
Address2:
E-Mail Address:
City:
State:
Zip:
Injury Information
Is injury condition related to:
Select
Work
School
Auto Accident
None
*
Date of Accident:
Part of Body Injured:
Do you have an attorney for this injury?
Yes
No
If Yes Do you authorize this office to submit medical and billing information to your attorney:
Yes
No
Name of attorney:
Phone:
Address:
Address2:
City:
State:
Zip:
Medical Insurance Information
Primary Insurance
INSURANCE CO:
*
POLICY HOLDER'S NAME:
*
Policy Holder's SS:
*
Policy Holders Relationship to Patient:
Select
Self
Spouse
Parent
Other
*
Policy Holder's Date of Birth:
*
Employer:
*
INS.CO Address:
Floor/Suite:
City:
State:
Zip:
Phone:
ID:
*
Group/Policy:
*
Referral Required:
Yes
No
*
Secondary Insurance
INSURANCE CO:
POLICY HOLDER'S NAME:
Policy Holder's SS:
Policy Holders Relationship to Patient:
Select
Self
Spouse
Parent
Other
Policy Holder's Date of Birth:
Employer:
INS.CO Address:
Floor/Suite:
City:
State:
Zip:
Phone:
ID:
Group/Policy:
Referral Required:
Yes
No
Patient Name:
*
Date:
*
Please answer the following questions- Do you have:
Fever/Chills?
Yes
NO
Sensitivity to heat?
Yes
NO
Unexplained Weight Loss?
Yes
NO
Sensitivity to cold?
Yes
NO
Recent Weight Loss?
Yes
NO
Skin rash?
Yes
NO
Glasses/contact lenses?
Yes
NO
Open Sores?
Yes
NO
Hearing Loss?
Yes
NO
Headaches?
Yes
NO
Oxygen Dependence?
Yes
NO
Dizziness?
Yes
NO
Sleep apnea?
Yes
NO
Anxiety?
Yes
NO
Shortness of breath?
Yes
NO
Depression?
Yes
NO
Easy bruising/bleeding?
Yes
NO
Environmental allergies?
Yes
NO
GI Bleed/Black Stool?
Yes
NO
Please list the medications you are currently taking.
Medication Name
Strength
Condition(i.e high blood pressure,diabetes,thyroid problems,etc.)
*
Please list any allergies below.
Emergency Contact:
Relationship:
Emergency Contact Phone Number:
Pharmacy Name:
Pharmacy Address:
Pharmacy Address2:
City:
State:
Zip:
Telephone Number:
Smoke:
Yes
NO
Frequency:
Packs Per day:
Select
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
Occasionally:
How Many:
Select
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
Alcholic Beverages:
Yes
NO
Frequency:
Occasionally:
Please list all past general surgeries:
SURGERY
DATE
DOCTOR
*
*
*
List any Orthopaedic Surgeries:
DATE
DOCTOR
*
*
*
I CONSENT TO MEDICAL TREATMENT BY FRANK FEMINO MD,STEPHEN DUCEY MD,SETH QUELER MD,AND I HEREBY AUTHORIZE FEMINO-DUCEY-QUELER ORTHOPAEDIC GROUP TO FURNISH INFORMATION TO INSURANCE CARRIERS CONCERNING MY ILLNESS AND TREATMENT. I HEREBY ASSIGN TO FEMINO-DUCEY-QUELER ORTHOPAEDIC GROUP ALL PAYMENT FOR MEDICAL AND OR SURGICAL SERVICES RENDERED TO MYSELF OR MY DEPENDENTS.I UNDERSTAND THAT I AM RESPONSIBLE FOR ANY AMOUNT NOT COVERED BY INSURANCE. I AGREE TO PAY ALL COSTS OF COLLECTION,INCLUDING A REASONABLE ATTORNEY'S FEES.SHOULD THIS ACCOUNT BE PLACED WITH AN ATTORNEY FOR COLLECTION.
INITIAL:
*
DATE:
*
Captcha