Attention! Please fill out the Patient Registration Form before you log into the patient portal. Thank you. Note: All fields are required. If they do not apply, simply enter “n/a“. Patient Registration Form First Name Middle Name Last Name Phone Number Address 1 Address 2 City State Zip Code Email Gender Social Security Number Referring Physican Referring Physician Phone Number Primary Care Physician Primary Care Phone Number Employer Employer Phone Emergency Contact (Name & Relationship) Emergency Phone Number Pharmacy Name Pharmacy Phone Pharmacy Fax Workman's Comp or Motor Vehicle Related? (Yes/No) Workman’s Comp or Motor Vehicle related: Claim Number Workman’s Comp or Motor Vehicle related: Insurance Adjuster Name & Number Workman’s Comp or Motor Vehicle related: Insurance Carrier Workman’s Comp or Motor Vehicle related: Insurance Address Primary Health Insurance: Carrier Primary Health Insurance: ID Number Primary Health Insurance: Group Number Insured Name Primary Health Insurance: Phone Number Primary Health Insurance: Date of Birth Primary Health Insurance: Social Security Number Occupation (If retired please fill in ||retired||) What is your dominant hand (right/left)? Location of Current Pain How severe is the pain? (Scale of 1-10) Are there specific aggravating factors? Are there specific relieving factors? By typing ||Yes||, I consent to be examined by High Mountain Orthopedics and their respective physicians at each visit. I agree to allow them to release my records to the insurance carrier or its representative any information necessary to determine my benefits. I also assign payments to High Mountain Orthopedics. I understand that payment is required at the time of each visit/service unless otherwise agreed to with the billing department. I understand that I am responsible for all charges incurred regardless of any problem that may arise with the insurance. Electronic Signature (Please type your name) Today's Date Number Submit Share this:Share on X (Twitter)Share on FacebookShare on LinkedInShare on Email