Appointment Request – Existing Patient | Orthopedic Surgery, P.C.

Existing Patient Appointment

Please use this form if you are requesting an appointment for a problem we are currently treating or have treated you for in the past. For your safety, if you are having a medical emergency, please go to the nearest emergency room rather than request an appointment at this time. If you have never been seen at our offices or if you have a new orthopedic problem that we have not treated you for in the past, please go to the New Patient Tab.

For your convenience and to minimize the chance that we are not participating with your insurance plan, please review the list of plans with which we are currently contracted to provide services to our patients.

Contact Information:
* Indicates required field

Regarding your appointment request please let us know if this is

New Injury
Being treated already for this injury *

First Name:

Middle Initial:

Last Name:

Address, 1st Line:

Address, 2nd Line:

City:

State:

Zip:

Best phone number to reach you: (XXX-XXX-XXXX)

Alternate phone number: (XXX-XXX-XXXX)

2nd alternate phone number: (XXX-XXX-XXXX)

Social Security Number: (XXX-XX-XXXX)

Date of Birth: (mm/dd/yyyy)

E-mail Address:

Insurance Company:

Other payer (i.e. Worker’s Comp, Auto Insurance, Self Pay):

Is this orthopedic problem a work-related injury?

Yes No Unsure *

Is this orthopedic problem related to an automobile accident?

Yes No Unsure *

Appointment Information:

Which office would you like to visit?

Which time of day do you prefer?

Which physician or physician assistant has been treating you for this problem?

Please provide a brief description of the orthopedic problem you are currently being treated for:

I understand that Orthopedic Surgery, P.C., cannot guarantee privacy for e-mail communications via the Internet. I understand and accept this risk and allow Orthopedic Surgery, P.C., to communicate my protected health information using my personal e-mail address listed above.

For Patients