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