PATIENT INTAKE FORM
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JEFFERSON ORTHOPEDIC CLINIC
Mark Juneau, Jr., M.D.
Matthew R. Grimm, M.D.
Wesley A. Clark, M.D.
Barton L. Wax, M.D.
Scott A. Tucker, M.D.
John M. Kesler, PA-C
PREFERRED PROVIDER
PREFERRED PHARMACY
PREFERRED PHARMACY
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PATIENT
PATIENT
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EMPLOYER (or Parents Employer)
EMPLOYER (or Parents Employer)
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Emergency Contact (Friend or Relative not living with you)
Emergency Contact (Friend or Relative not living with you)
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SPOUSE INFORMATION
SPOUSE INFORMATION
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INSURANCE INFORMATION
INSURANCE INFORMATION
Give insurance card and Driver's License to receptionist upon arrival
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SECONADARY INSURANCE INFORMATION
SECONADARY INSURANCE INFORMATION
Give insurance card and Driver's License to receptionist upon arrival
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CONSENT FOR TREATMENT
CONSENT FOR TREATMENT
I as a patient consent to medical care including examination, diagnostic, or surgical treatment by the treating physician and such associates or assistants as may be deemed necessary. I am aware that the practice of medicine is not an exact science and that no guarantees have been made to me as to the results of any treatment.
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AUTHORIZED RELEASE OF INFORMATION
AUTHORIZED RELEASE OF INFORMATION
I hereby authorize Jefferson Orthopedic Clinic to release those medical records pertaining to my treatment to any entity that is responsible for payment of physician charges. I understand that this authorizes my insurance company to pay any benefits directly to Jefferson Orthopedic Clinic. In addition, I further understand that I am ultimately responsible for charges incurred for services rendered, and that collection fees will be added to balance not paid in a timely manner.
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CHIEF COMPLAINT - Why are you seeing the doctor today?
CHIEF COMPLAINT - Why are you seeing the doctor today?
Injured Body Part (Check all that apply)
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Your Current Medical Problem is the result of:
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This occurred during:
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HISTORY OF PRESENT ILLNESS:
HISTORY OF PRESENT ILLNESS:
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Describe it. Check all that apply.
When does your pain and discomfort occur? Check all that apply:
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What makes your pain or discomfort better? Check all that apply
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If yes, check all previous testing done:
Medications
Medications
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Current Medications (If you don't know how to spell the medication, please inform the nurse when seen)
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Are you currently or have you had problems with your:
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PAST MEDICAL HISTORY
PAST MEDICAL HISTORY
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FAMILY MEDICAL HISTORY
FAMILY MEDICAL HISTORY
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Mother
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Father:
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Sister/Brother:
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Children
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SOCIAL HISTORY
SOCIAL HISTORY
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ACKNOWLEDGEMENT OF OUR NOTICE OF PRIVACY PRACTICES
I hereby acknowledge that I have received or have been given the opportunity to receive a copy of Jefferson Orthopedic Clinic\'s Notice of Privacy Practices. By signing below I am "only" giving acknowledgement that I have received or have had the opportunity to receive the Notice of our Privacy Practices.
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Please sign your name in the area below
By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.