Pre-Visit Form

Date of Visit *

MM

DD

YYYY

Patient Name *

First Name

Last Name

Date Of Birth *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone

(###)

###

####

Cell Phone

(###)

###

####

May We Leave A Message?

Yes

No

Work Status

Full Time

Part Time

Living Status

Lives Alone

With Spouse

Skilled Nursing

With Other Person(s)

Emergency Contact *

First Name

Last Name

Emergency Contact Phone *

(###)

###

####

Which Knee(s)? *

Please Check All That Apply.

Left

Right

Were X-Ray's Taken? *

Yes

No

Subscriber's Name *

First Name

Last Name

Subscriber's Name

First Name

Last Name

By selecting the " I Agree to the Litigation Terms" check box below I am hereby certifying that I am not in any form of litigation regarding any current medical issue regarding but not limited to workers compensation or an auto injury. *

I Agree to the Litigation Terms

Patient Consent and Disclosure of Protected Health Information *

To the Patient: You have the right, as a patient, to be informed about your condition and the recommended surgical, medical or diagnostic procedure to be used so that you may make an informed decision whether or not to undergo any suggested treatment or procedure after knowing the risks and hazards involved. By signing this consent form, you authorize Dr. David R. Cooper to perform the evaluation necessary to identify the appropriate treatment and/or procedure for any identified condition(s). You authorize The Knee Center and Dr. David R. Cooper to disclose protected information about you to other physicians and/or treatment facilities directly responsible for your care. This consent provides us with your permission to perform reasonable and necessary medical examinations, testing and treatment. By selecting agree and submitting this form, you are agreeing that you intend this consent to be continuing in nature even after a specific diagnosis has been made and treatment recommended. This consent will remain fully effective until it is revoked in writing. You have the right at any time to discontinue services. You have the right to discuss the treatment plan with your Physician about the purpose, potential risks and benefits of any test ordered for you. If you have any concerns regarding any test or treatment recommended by your health care provider, we encourage you to ask questions. By selecting agree and submitting this form, you authorize payment of medical benefits to The Knee Center and Dr. David R. Cooper. Copays, coinsurance and deductibles are the responsibility of the patient. Copays are due at the time of service. I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents.

Agree

Authorization of Patient or Representative *

First Name

Last Name

Date *

MM

DD

YYYY