Intake Form

PERSONAL INFORMATION

First Name:

Middle Name:

Last Name:

Home Phone:

Best Contact Phone Number:

DOB:

Marital Status:

Employed Retired Student

School:

Address line 1:

Address line 2:

City:

State:

Zipcode:

Email:

Would you like to receive a text reminder ? Yes No

Patient's Employer:

Employer's Address:

Work Phone:

City:

State:

Zipcode:

PARENT / GUARDIAN / SPOUCE INFORMATION

First Name:

Middle Name:

Last Name:

Address line 1:

Address line 2:

Relationship to Patient: Parent Guardian Spouse

Home Phone:

DOB:

City:

State:

Zipcode:

Employer:

Work Phone:

Address:

City:

State:

Zipcode:

EMERGENCY CONTACT

Emergency Contact:

RelationShip:

Emergency Phone:

REFERRAL INFORMATION

Who can we thank for your referral to New Edge Orthopedics, LLC?

My doctor

Online

Friend or family

Other

INSURANCE INFORMATION

Primary Insurance

Insurance Company Name

Insurance Co. Address

Address line 1

Address line 2

Policy Holder's Name

Group Number

Policy Number

Effective Date

Secondary insurance/ School insurance/ Motor Vehicle insurance/ any other Medical coverage

Insurance Company Name

Insurance Co. Address

Address line 1

Address line 2

Policy Holder's Name

Group Number

Policy Number

Effective Date

CONSENT FOR TREATMENT - HIPAA PRIVACY

I hereby authorize New Edge Orthopedics, LLC to use and/or disclose a copy of my medical records containing individually identifiable health information as described below. | understand that this authorization is voluntary. | also understand that, if the organization authorized to receive the information is not a health care provider or health plan, the released information may no longer be protected by state or Federal privacy laws or this authorization.

PRIVACY PRACTICES

May we leave messages,which may include but are not limited to information about prescriptions or test results on your answering machine? No Yes

May we leave messages,which may include but are not limited to information about prescriptions or test results with members of your household? No Yes

PATIENT FINANCIAL RESPONSIBILITIES

ASSIGNMENT OF BENEFITS: I hereby assign all medical and Surgical benefits, to include major medical benefits to which I am entitled. I hereby authorize my insurance carrier(s), including Medicare, private insurance, and any other health/medical plan, to issue payments directly to New Edge Orthopedics, LLC for services rendered to myself and/or my dependents regardiess of my insurance benefits, if any. I understand that I am responsible for any amount not covered by insurance.
AUTHORIZATION TO RELEASE INFORMATION: I hereby authorize New Edge Orthopedics, LLC: (1) release any information necessary to insurance carriers regarding my treatment; (2) process insurance claims generated in the course of examination or treatment; and (3) allow a photocopy of my signature to be used to process insurance claims for the period of lifetime. This order will remain in effect until revoked by me in writing.
For HORIZON - BLUE CROSS/ BLUE SHIELD patients; at times, the checks for payment for services provided to you by New Edge Orthopedics, LLC / Dr El-Gazzar are sent directly to you as the patient. In that event, please sign the back of the check/ endorse the check and either mail or bring the check to a New Edge Orthopedics, LLC office within 2 weeks. Do not deposit the check from your medical insurance carrier into your bank account, this will result in you having to issue a check for the same amount to New Edge Orthopedics, LLC/ Dr. El-Gazzar.
It is possible that other insurance companies aside from BLUE CROSS / BLUE SHIELD can also issue the payments for services provided to you by New Edge Orthopedics, LLC/ Dr. El-Gazzar directly to you.
In that event, please follow the instructions as discussed above:
Please sign the back of the check/ endorse the check and either mail or bring the check to a New Edge Orthopedics, LLC office within 2 weeks. Do not deposit the check from your medical insurance carrier into your bank account, this will result in you having to issue a check for the same amount to New Edge Orthopedics, LLC/ Dr. El-Gazzar.
In the event that your medical insurance carrier has issued the payment for services directly to you, please bring the EOB (explanation of benefits) documents that accompanied the check to the office as well when you bring it / mail your insurance company's check to New Edge Orthopedics, LLC.

AUTHORIZATION

By filming my name here and clicking submit, I accept that my entered name is a legal signature agreeing to the terms as described above

Patient Signature:

Date:

Parent/ Guardian/ Power of attorney/ Health Care proxy

Relationship to Patient

Reason that patient is not signing for themselves (For example patient is a minor)

Medical History Form

Please fill this form as accurately as possible to the best of your ability to help us treat you.

PERSONAL INFORMATION

First Name:

Middle Name:

Last Name:

Age:

Date of Birth:

Best Contact Phone Number:

Occupation:

How did you learn about our practice (referred by)?

Address line 1:

Address line 2:

City:

State:

Zipcode:

Email:

Marital Status: Single Married Divorced Widowed

Are you (Please check One): A New Patient To The Practice An Established Patient To The Practice

MEDICATION

Are you currently taking any medications? (If yes, please list below) Yes No

Are you currently taking an Immunosuppressant? Yes No

ALLERGIES

Do you have any medication related allergies? Yes No

Do you have any non-medication related allergies? Yes No

Latex
Nickels / Metals
Cinnamon
Poultry
Shell Fish
Seasonal
Other

MEDICAL HISTORY

Please check any conditions that you have had in the past or have currently

Height:

Weight:

No Significant Medical History To Report:

SURGICAL HISTORY

Orthopedic:

UPPER EXTREMITY

LOWER EXTREMITY:

Non-Orthopedic Surgery:

FAMILY HISTORY

ACTIVITY LEVEL

INACTIVE (Normal activitied of daily living)

LIGHT (Some activity; walking, gardening, occasional weekend recreational exercise)

MODERATE (regular 3x per week moderate exercise, weekend athletics)

VIGOROUS (regular 3-5x per week vidorous exercise and/or athletics weekly)

INTENSE (competitive daily vigorous sports training)

SOCIAL HISTORY

Have you fallen in the last 6 months? Yes No

Do you feel steady on your feet? Yes No

PAIN LEVEL

Please select the number the describe your current pain level

0: No Hurt
2: Hurts Little Bit
4: Hurts Little More
6: Hurts Even More
8: Hurts Whole Lot
10: Hurts Worst

REVIEW OF SYMPTOMS

Have you experienced any of the following symptoms over the past 6 months?

Patient Signature

Date

Injury Form

Please fill this form as accurately as possible to the best of your ability to help us treat you.

Patient Name:

How you were injured?

Car Accident
Hit By Car
Motorcycle Accident
Work related injury / Workman Comp
School/ sports injury. - Which school or Sports Team?
Other (please describe):

Date of injury:

Body Parts injured (include right or left):

Please describe how the injury occurred and where on the date you listed above:

Signature of Patient or Guardian:

Covid-19 Screener

Please fill this form as accurately as possible to the best of your ability to help us treat you.

As you are aware, due to the current COVID-19 coronavirus pandemic, we must make every effort to insure that all safety measures have been taken to protect our patients, staff, and families.

It is mandatory that the following COVID-19 screening form is filled out by every patient and submitted prior to every office visit.

Please fill out this form to the best of your ability and as truthfully as possible to help us maximize the safety of our patients, staff, and families. Answering yes to any of the screener questions does not mean that service will be denied.

Name :

Are you experiencing any (or worsening) fever, cough, shortness of breath, sore throat, loss of taste or smell, abdominal pain, diarrhea, fatigue, or any new onset symptom possibly related to COVID-19 exposure/infection?
Yes No

In the last 14 days, have you had contact with someone who has been confirmed or suspected to be exposed or diagnosed with COVID-19 coronavirus infection?
Yes No

Have you traveled overseas in the past 2 weeks?
Yes No

Have you traveled within the past 14 days to one of the states currently listed by New Jersey state government as part of the 14 day quarantine travel advisory announced by the governor of New Jersey? (Click on the link below to identify which states and jurisdictions are on the travel advisory list)
Click Here
Yes No

A Message About The Current COVID-19 Precautions Taken at New Edge Orthopedics, LLC

To all our friends, families, patients, and supporters, we are blessed to report that New Edge Orthopedics, LLC is back on track and reopened while making accommodations in response to this unprecedented challenge/ pandemic. We are exercising great care ensuring that we provide the safest environment possible for our patients, staff, and families including:

Maintaining strict social distancing and mask policy, (Surgical grade masks, gloves, and sanitizer available)
Touch-less temperature checks prior to entry beyond the front desk
COVID-19 screening prior to appt (on our website or via phone interview)
Rigorous sanitizing of all patient areas (the waiting room, exam rooms, bathrooms, and x-ray room with CDC approved anti-viral disinfectant wipe down and UV-C light anti-viral treatment throughout the day between every patient
UV-C light air purifiers running full time sanitizing and filtering the air circulated in the office
Careful timing of patients’ appts to ensure that there is minimal overlap and wait times with the goal of avoiding having any patients in the waiting room throughout the day as much as possible
We ask all patients to check-in just prior to their appt before coming up

We look forward to celebrating unity as we work together fighting this pandemic while providing the Best Orthopedic Sports Medicine and Joint Preservation care to our Patients and Family.

Stay safe & healthy!
Respectfully,
All of us at NEO

Intake Form

Primary Insurance

Secondary insurance/ School insurance/ Motor Vehicle insurance/ any other Medical coverage

Medical History Form

Please fill this form as accurately as possible to the best of your ability to help us treat you.

Orthopedic:

UPPER EXTREMITY

LOWER EXTREMITY:

Non-Orthopedic Surgery:

1. Occupation

2. Smoking status

3. Alcohol intake

4. Drug use

5. Personal recreation and activity level:

Injury Form

Please fill this form as accurately as possible to the best of your ability to help us treat you.

Covid-19 Screener

Please fill this form as accurately as possible to the best of your ability to help us treat you.

A Message About The Current COVID-19 Precautions Taken at New Edge Orthopedics, LLC

Intake Form

Primary Insurance

Secondary insurance/ School insurance/ Motor Vehicle insurance/ any other Medical coverage

Medical History Form

Please fill this form as accurately as possible to the best of your ability to help us treat you.

Orthopedic:

UPPER EXTREMITY

LOWER EXTREMITY:

Non-Orthopedic Surgery:

1. Occupation

2. Smoking status

3. Alcohol intake

4. Drug use

5. Personal recreation and activity level:

Injury Form

Please fill this form as accurately as possible to the best of your ability to help us treat you.

Covid-19 Screener

Please fill this form as accurately as possible to the best of your ability to help us treat you.

A Message About The Current COVID-19 Precautions Taken at New Edge Orthopedics, LLC

Patients with current appointments

Current Patient with a new problem

Current Patient with a new problem

Current Patient with a new problem