| Print this Page |
Orthopedic Group, Inc |
Office Information: Medical Forms
Paperwork can sometimes be overwhelming at registration time. To help facilitate the process, we have provided several forms on this web site that you can print out and complete prior to your visit. Please remember to bring them along for you appointment. This will help reduce the time you spend in the waiting room.
Orthopedic Group:
If you are receiving orthopedic care, please complete the appropriate forms from the list below.
- Registration: If you are a new patient, please complete this form. It includes basic patient demographics and insurance information.
- Patient History: If you are a new patient, please complete this form. We use this form to compile an accurate medical history in order to treat the patient appropriately.
- Records Release Authorization: If you would like your medical records forwarded to a third party, please complete and submit this form to our medical records department. In order to safeguard your privacy, we will contact you via telephone to confirm your authorization. In all instances, the patient’s is required.
- Financial Agreement: If you are a new patient, please complete this form.
- Notice of Privacy Practices
Cosmetic Procedure Forms:
If you are receiving cosmetic procedures, please complete the appropriate forms from the list below.
General
Comments and Responses
Injection Site Records
Patient Analysis and Operative Report
Patient Progress Record
Cosmetic Clinic Fee Schedule
Botox
Botox Medical History
Consent to Botox® Botulinum Toxin "A" Treatment
Botulinum Injection Records
Botox Pre-Treatment Instructions
Botox Post-Treatment Instructions
Dermal Fillers
Medical History for Dermal Fillers
Patient Information for Dermal Fillers
Consent for Treatment
Pre-Treatment Instructions for Dermal Fillers
Post-Treatment Instructions for Dermal Fillers
Sclerotherapy
Patient History and Physical for the Treatment of Sclerotherapy
Sclerotherapy Informed Consent Form
Sclerotherapy Treatment Flow Sheet
Pre-Sclerotherapy Instructions
Post-Sclerotherapy Instructions
|