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