PATIENT REGISTRATION FORM
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
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
PATIENT
PATIENT
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please select an option.
Please select an option.
Please select an option.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please select an option.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please select an option.
Please select an option.
Please select an option.
Please complete this field.
Please complete this field.
Please complete this field.
Please select an option.
Please complete this field.
EMPLOYER (or Parents Employer)
EMPLOYER (or Parents Employer)
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Emergency Contact (Friend or Relative not living with you)
Emergency Contact (Friend or Relative not living with you)
Please complete this field.
Please complete this field.
Please complete this field.
SPOUSE INFORMATION
SPOUSE INFORMATION
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
INSURANCE INFORMATION
INSURANCE INFORMATION
Give insurance card and Driver's License to receptionist upon arrival
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
SECONADARY INSURANCE INFORMATION
SECONADARY INSURANCE INFORMATION
Give insurance card and Driver's License to receptionist upon arrival
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
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.
Please complete this field.
Please complete this field.
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.
Please complete this field.
Please complete this field.