Attention!

Please fill out the Patient Registration Form before you log into the patient portal. All fields are required. If they do not apply, simply enter “n/a”. Thank You!

Patient Information
Name:
Address:
E-mail:
Cell Phone:
-
Home Phone:
-
Date of Birth
Gender
Social Security #
Referring Physician & Other Doctor Information
Referring Doctor
Primary Care Physician
Referring Doctor Phone Number
Primary Care Physician Phone
Employer & Emergency Contact
Employer
Employer Phone
Emergency Phone
Pharmacy Information
Pharmacy Name
Pharmacy Fax
Pharmacy Phone
Insurance Information
Insured Name
Insured Date of Birth
Primary Health Insurance Carrier
Primary Health Insurance ID #
Primary Health Insurance Group #
Primary Health Insurance Phone #
Workman's Comp / Motor Vehicle Related
Workman's Comp or Motor Vehical?
Insurance Adjusters Number
Insurance Adjusters Name
Claim Number
About You and Your Pain
Dominant Hand
Are there specific aggravating factors?
Are there specific relieving factors?
Where is your current pain?
Consent & Signature
By selecting "Yes", I consent to be examined by High Mountain Orthopedics and their staff.
Electronic Signature (Type Name)
Todays Date:

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