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Premier Orthopedics, P.A.

Appointment Request

Please select an answer for each question below, then click the submit button at the bottom.
* Are You A Current Patient of Premier Orthopedics, P.A.? Yes     No    
* Do You Have Health Insurance? Yes     No    
  Name of Insurance Company
* Is Your Problem The Result of An Automobile Injury? Yes     No    
* Is Your Injury Part of A Workers’ Compensation Case? Yes     No    
* If This Is A Workers’ Compensation Case, Are You A Professional Athlete? Yes     No    
* Is This A Department of Labor Case? Yes     No    
* If This Is A Workers’ Compensation Case, Is This A New Injury? Yes     No    
* Have you had x-rays or MRIs taken elsewhere related to your current problem? Yes     No    
  If yes, where and when performed?
* Describe your current problem:
* Is This A Fracture or Broken Bone? Yes     No    
* Do You Think You Have A Sprain or Torn Ligament? Yes     No    
* Have you had multiple surgeries for the existing problem before? Yes     No    
* Are You Getting A Second Opinion? Yes     No    
* Have You or Are You Being Referred To Us? Yes     No    
  If so by whom:
* Are You Being Treated For An Injury That Involves Litigation or Legal Recourse? Yes     No    
* Do you plan on paying for Premier Orthopedics, P.A. services yourself?
cash payment or self pay)
Yes     No    
PATIENT INFORMATION
* First Name
* Last Name
  Middle Initial
* Date of Birth
  Home Phone
  Work Phone
  Cell Phone
* Address
Please provide full mailing address