New Patient Registration Update Registration

Office Location: Wexford     Jefferson

Patient's Last Name:

Patient's First Name: Middle Initial:

Address :

City:       State:       Zip:

Gender: Male Female

Marital Status: -- Married Single Divorced Widow/Widower Other

Spouse Name:

Home Phone: ( ) - Work Phone: ( ) -

Cell Phone : ( ) -

E-mail Address:

CHIEF COMPLAINT/INJURY:

History of injury:

Date of Onset: MonthJanuaryFebruaryMarchApril MayJuneJulyAugustSeptember OctoberNovemberDecember Date123456 789101112 131415161718 192021222324 252627282930 31 Year:

Referring Physician:

Family Physician:

Family Physician's Address:

City:       State:       Zip:

Family Physician's Phone Number: ( ) -

Employer's Name:

Employer's Address:

City:       State:       Zip:

Employer's Phone Number: ( ) - ext:

Occupation:

IS THIS WORK RELATED? Yes No

If yes, please return to the patient registration screen and use the Worker's Comp register link.

ARE YOU CURRENTLY WORKING? Yes No

LAST DATE WORKED: MonthJanuaryFebruaryMarchApril MayJuneJulyAugustSeptember OctoberNovemberDecember Date123456 789101112 131415161718 192021222324 252627282930 31 Year:

Was injury related to autmobiles?   Yes No

Is another party or individual (homeowners, school, personal liability) responsible for your injuries? Yes No

Have you initiated any legal action? Yes No

Date of Injury: Month January February March April May June July August September October November December Date 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year:

Primary Insurance:

Insurance Company Name:

Insurance Address:

City:   State:       Zip:

Phone Number: ( ) -

Insurance ID#:

Group #:

Subscriber:

Subscriber's Birthday: Month January February March April May June July August September October November December Date 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year:

If Applicable, Adjustor's Name:

Secondary Insurance:

Insurance Company Name:

Insurance Address:

City:   State:       Zip:

Phone Number: ( ) -

Insurance ID#:

Group #:

Subscriber:

Subscriber's Birthday: Month January February March April May June July August September October November December Date 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year:

If Applicable, Adjustor's Name:

Dominant Hand: Left Right

Height:      Weight:

Were X-Rays taken? Yes No

If yes, where were the X-Rays taken?

What part of the body was X-Rayed?

Any further testing performed, such as (Please check all that apply):

MRI

CT Scan

EMG/NCS

Bone Scan

Prior Operative Report

All other Medical Records

ALL FILMS AND REPORTS PERTAINING TO THIS APPOINTMENT MUST BE RECEIVED PRIOR TO YOUR VISIT by having them faxed to us at (724) 933-3860 or bring them at the time of your visit.

If patient is under 18:

Parent/Guardian's Last Name:

Parent/Guardian's First Name:

Parent/Guardian's Phone Number: ( ) -

Parent/Guardian's Cell Phone Number: ( ) -

Relationship with minor: