For New Patient

Please use this form if you have never been seen at our offices. 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 are requesting an appointment for a problem we are currently treating or have treated you for in the past, please go to the Existing 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

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 would you prefer to see?

 *

Please give us a brief description of the problem you are having:
*

Please complete the online forms and bring them with you to your appointment, along with:

  • Photo ID
  • Your insurance card if you would like us to file a claim for your care
  • A list of your current medications (if you have not included that information on the Medical History Form
  • Any recent films, reports or other diagnostic tests related to this problem
  • Medical records related to any previous treatment you have had related to this problem


Please plan to arrive 15 minutes before your scheduled appointment time so that all necessary registration details can be handled before you see the doctor or physician assistant.

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.
CAPTCHA Image
Reload Image