I hereby authorize Mousam Valley Orthopaedics to furnish information to any applicable insurance carrier(s) concerning any illness and treatments as requested for determination of a claim.  I hereby assign Mousam Valley Orthopaedics all payments for medical services rendered. I understand that I will be notified of any such payments to the provider of service and that I am financially responsible to the provider for charges not covered by my insurance.
     I hereby request service be provided by Mousam Valley Orthopaedics to provide care and treatment.

Date:___________     Parent/Responsible Party Signature: ___________________________________
 
 

What part of your body is troubling you?____________Left______________ Right_______________
Referring Doctor:______________________________
Date of Injury:________________________________
Current Age:_________________________________
Family doctor/primary care physician:___________________________________________________
Do you smoke?________________
Marital Status:  Single_____  Married_____ Widowed_____ Divorced_____
Allergies:  Yes_____ No_____
To What?________________________________________________________________________
Please list current medications:_________________________________________________________
________________________________________________________________________________
Please list surgeries:_________________________________________________________________
 
 

Patient Name:______________________________________________________________________
                                          (Last)                                                    (First)                                     (MI)
Date of Birth:___________________________Social Security Number:_________________________
Mailing Address:____________________________________________________________________
City:_______________________________ State:_______________ Zip Code:__________________
Home Phone:_______________________________Work Phone:_____________________________
Sex: M___ F____
Religion Preference (optional):____________________________________
 
 

Father's Name: _______________________________  Home Phone:____________________
Father's Address:______________________________  Work Phone:____________________
___________________________________________
Employer:____________________________________  SSN:__________________________

Mother's Name:_______________________________  Home Phone:____________________
Mother's Address (if different):____________________  Work Phone:____________________
___________________________________________
Employer: ___________________________________  SSN:__________________________

The policy in our office is: The parent who requests treatment for the child is
responsible for all fees for services rendered.
Signature of Parent/Responsible Party:______________________________________________

Patient's Employer:_______________________________
Address:_______________________________________   Work Phone:__________________
Spouse's Name:__________________________________
Spouse's Employer:________________________________________________
Person to Notify in Case of Emergency:__________________________  Phone No:___________

Primary Insurance:_________________________________  Policy Holder:_________________
Certificate # _____________________________________  Group #______________________
Secondary Insurance:_______________________________  Policy Holder:_________________
Certificate #______________________________________ Group #______________________
Employer:_____________________________________________  Tel.#___________________
Is this injury related to a motor vehicle accident?___________________________
If so, name of insurance and policy number:_____________________________________________
Are you or will you be represented by an attorney?________________________________________

Is this Workers' Compensation? __________________  YES __________________ NO
Employer:____________________________________________   W/C Ins: Co.________________
Employer Address:__________________________________  W/C Ins. address:________________
________________________________________________
Occupation:_________________________________________________