New Patient Form

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Patient First Name

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Patient Last Name

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Consent to Treatment

As a DOM Patient, I voluntarily consent to the rendering of such care and treatment as the DOM providers and personnel, in their professional judgment, deem necessary for my health and well-being. My Consent shall include all diagnostic procedures and/or medical, lab, surgical or x-ray treatment which in the judgment of my attending physician or his authorized agent, may be considered necessary or advisable. I also authorize release of information to the Poison Center if required as part of my treatment.

Consent to Call

I Understand and agree that DOM may contact me using automated calls, email, and text messaging sent to my landline and mobile device. These communications may notify me of preventive care test, tests results, treatment recommendations, outstanding balances, or any communication from DOM.
I understand that I may voluntarily "opt-in" to receive automated text messaging communications from DOM and its partners by informing my provider's staff or visiting "My Profile" on my Patient Portal, and agreeing to any additional Terms and Conditions established by my mobile carrier.
I hereby acknowledge that I have received DOM's Financial Policy, the sharing of my information via HIE and consent to my treatment by DOM provider.

Signature:

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Date:

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Please provide your email or mobile number for a good review on a survey after your visit today.

PCP:

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Pharmacy:

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Financial Policy

PAYMENT IS DUE AT THE TIME OF CONSULT OR OFFICE VISIT.
WE ACCEPT CASH, CHECKS, VISA, MASTERCARD, OR MONEY ORDERS.
WE OFFER EXTENDED PAYMENT (BUDGET) PLAN. Contact our billing office to make arrangements at 724-261-4080.

Insurance Authorization and Assignment

I request that payment of authorized insurance benefits be made on my behalf to DiCesare Orthopedic medicine for any services furnished to me. I hereby authorize DiCesare Orthopedic Medicine to release any medical information necessary to process my claim. I permit a copy of this authorization be used in place of the original. The authorization may be revoked either by me or my insurance company at anytime in writing.

I understand and agree to this Financial Policy

Signature:

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Date:

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For Medicare Patients Only

I request that payment of authorized Medicare benefits be made on my behalf to the provider to any services furnished to me by the physician or provider. I authorize any holder of medical information about me to release to the Centers for Medicare and Medicaid Services and its agents any information needed to determine these benefits payable for related services

Signature:

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Date:

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ACKNOWLEDGEMENT RECEIPT OF NOTICE OF PRIVACY PRACTICES

DiCesare Orthopedic Medicine has a NOTICE OF PRIVACY PRACTICES which describes how we may use disclose your protected health information. You may review our current notice prior to signing this acknowledgment. It is located on our website "www.greensburgortho.com".

I acknowledge that I have received the NOTICE OF PRIVACY PRACTICES for DiCesare Orthopedic Medicine.

Name of Patient:

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DOB:

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Signature:

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Date:

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Please specify to whom other than yourself, we may release your Protected Health Information(PHI).

Name:

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Name:

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Name:

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Emergency Contact:

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Phone:

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Are we permitted to leave messages on your voicemail?

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New Patient Questionnaire

Today's Date:

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Name:

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Date of Birth:

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Age:

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ARE ADVANCE DIRECTIVES IN PLACE?

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Primary Care Physician:

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Referring Physician:

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Blood Pressure:

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Pulse:

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Height:

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Weight:

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Please list all the medication that you are taking (including over the counter medications) and the medical reason you take each medication:

None

Medication

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Dose

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Frequency

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Reason for taking Medication

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Medication

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Dose

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Frequency

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Reason for taking Medication

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Medication

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Dose

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Frequency

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Reason for taking Medication

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Medication

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Dose

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Frequency

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Reason for taking Medication

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Medication

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Dose

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Frequency

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Reason for taking Medication

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Please list any medical diagnoses that you currently have or have had in the past:

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FEMALES ONLY:

Is there any chance of Pregnancy?

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If yes, weeks pregnant

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When was the first day of your last menstrual cycle?

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Post Menopausal?

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Please list your surgical history:

Surgery:

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Date/Year:

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Surgery

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Date/Year:

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Surgery:

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Date/Year:

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Surgery

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Date/Year:

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Surgery

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Date/Year:

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HISTORY OF PROBLEM

Please describe what you are being seen for today.

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When did your symptom start?

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What have you tried for this problem? (Medications, physical therapy, chiropractic treatment, injections, etc.)

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Have you had any testing such as x-rays, CT, MRI or nerve conduction studies done?

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What doctors have you seen for this problem?

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PHARMACY

Please list the current pharmacy(s) you normally use for your prescriptions.

Name

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Address

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Phone Number

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Name

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Address

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Phone Number

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Name

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Address

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Phone Number

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Do you have a Latex Allergy?

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Do you have any known DRUG Allergies?

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If Yes, please list

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Social History

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Do you live alone?

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Are you a caregiver for a family member at home?

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If yes, for whom?

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What is your smoking history?

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# of packs a day

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Are you Right or Left Handed

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Do you chew tobacco?

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If Yes, how often?

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# of drinks per day

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Do you use street or recreational drugs?

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If yes, what type?

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Is your family history unknown due to adoption?

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Is your mother alive?

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If no, Please list cause of death and age

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Is your father alive?

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If no, please list cause and age of death

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Please mark all that apply to your IMMEDIATE FAMILY: (Parents, Siblings, and Grandparents only)

Unknown

Heart Disease

Liver Disease

Lung Disease

Kidney Disease

Hypertension

Diabetes

Asthma

Stroke

Malignant Hyperthermia

Cancer

Type

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Other

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Review of Systems: (Please circle all that apply to what you are currently experiencing with your overall health)

Gastrointestinal

Constitutional

Neurological

Skin

Genital/ Urinary

Psych

Muskoloskeletal

Ulcer Colitis

Fever

Weakness tingling in arms/ legs

Chronic Rashes

Abrasion

Pregnant

Anxiety

Swelling in multiple joint

Frequent indigestion

Blood in Stool

Chills

Numbness

Lacerations

Menopause

Depression

Excessive Flexibility of Joint

Fibromyalgia

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.

Drivers License

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