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Patient Registration

Please complete this entire form prior to your appointment. 

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Full Name *
Date of Birth *
Which Doctor are you seeing? *
Appointment Date *
Reason For Your Appointment
Is this the result of an injury?*
Have you see one of our doctors before? *
Marital Status *
If Yes, Who/When?
E-mail Address *
Cell Phone Number
    Phone Number *
      Work Phone Number
        Street Address
        Emergency Contact *
        Postal / Zip Code
        Emergency Contact Phone Number *
          How did you hear about our office?
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          Guarantor (Person responsible for payment) *
          Do you have medical insurance? *
          Primary Insurance Name
          Primary Insurance Company
          Relationship to Guarantor *
          Primary Insurance ID Number
          Primary Insurance Date of Birth
          Primary Insurance Group Number
          Do you have secondary medical insurance? *
          Secondary Insurance Name
          Secondary Insurance Company
          Secondary Insurance ID Number
          Secondary Insurance Name Date of Birth
          Secondary Insurance Group Number
          Medicaid ID Number (If applicable)
          Accept Terms *

          I authorize the medical to release any information, including diagnosis, treatment plans/records and radiographs to third party payers and/or health practitioners. I authorize and request that my insurance company (if applicable) pay directly to the medical group or medical benefits that are, otherwise, payable to me. I understand that my medical insurance may pay less than the actual bill for service or may not cover certain treatment.


          I hereby certify that the foregoing information is accurate and complete and that in consideration of treatment and services rendered to me or my dependents by this medical office, I accept responsibility and agree to be obligated to pay the office in accordance with its payment and credit terms and policies.


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          Orthopedic & Sports Medicine Center

          Office Hours:

          Monday-Friday 8:00am – 4:30pm