Patient Information


Last Name: * First Name: * Date of Birth: *
Sex: * Marital Status: * 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: * Date of Accident:    
Part of Body Injured: Do you have an attorney for this injury?
If Yes Do you authorize this office to submit medical and billing information to your attorney:    
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: *    
Policy Holder's Date of Birth: * Employer: *    
INS.CO Address: Floor/Suite:    
City: State: Zip:
Phone: ID: * Group/Policy: *
Referral Required: *        

Secondary Insurance
INSURANCE CO: POLICY HOLDER'S NAME:    
Policy Holder's SS: Policy Holders Relationship to Patient:    
Policy Holder's Date of Birth: Employer:    
INS.CO Address: Floor/Suite:    
City: State: Zip:
Phone: ID: Group/Policy:
Referral Required:        

Patient Name:

*

Date:

*
   
 
Please answer the following questions- Do you have:
Fever/Chills? Sensitivity to heat?    
Unexplained Weight Loss? Sensitivity to cold?    
Recent Weight Loss? Skin rash?    
Glasses/contact lenses? Open Sores?    
Hearing Loss? Headaches?    
Oxygen Dependence? Dizziness?    
Sleep apnea? Anxiety?    
Shortness of breath? Depression?    
Easy bruising/bleeding? Environmental allergies?    
GI Bleed/Black Stool?    
 
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: Frequency: Packs Per day:
Occasionally: How Many:
Alcholic Beverages: 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:

*
   
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