Intake Form

New Edge Orthopedics, LLC Yaser El-Gazzar, M.D.

Injury Report Form

Please use this form to describe in your words how you were injured.

Date of injury:

Body Parts injured (include right or left) :

In your own words, please describe how the injury occurred and where on the date you listed above:

I,

Name

am signing below that the above description is the truth and factual information to the best of my knowledge. I also understand that any deviations from the facts of the actual event listed here or given to the medical staff as history of injury/illness is considered fraud.

Signature of Patient or Guardian:

Date

PATIENT INFORMATION FORM

PERSONAL INFORMATION

INFORMATION Patient Name (include Ml):

Account Number:

Home Phone:

SSN:

DOB:

Marital Status

Cell Phone:

check one

Employed
Retired
Student / School

Address

Address Line 1

City

State

Zip Code

Would you like to receive a text reminder?

Yes
No

Email

Patient's Employer:

Work Phone:

Employer's Address

Address Line 1

City

State

Zip Code

PARENT / GUARDIAN / SPOUSE INFORMATION

Full Name:

DOB

Relationship to Patient

Parent
Guardian
Spouse

Address

Address Line 1

City

State

Zip Code

Home Phone:

SSN:

Employer:

Work Phone:

Address

Address Line 1

City

State

Zip Code

CONDITION / INJURY INFORMATION

Condition / Injury being seen for:

How and where did it occur?

X-rays Taken?

Yes
No

Location

When

Injury?

Yes
No

Date Occurred:

Work Related?

Yes
No

Emergency Contact:

Relationship:

Emergency Phone:

Referred by Dr.:

Address

Phone

Family Dr.:

Address

Phone

INSURANCE INFORMATION

Insurance Company Name

Insurance Company Name Primary

Insurance Company Name Secondary

Insurance Co. Address

Insurance Co. Address Secondary

Insurance Co. City, State, Zip

Insurance Co. City, State, Zip Secondary

Policy Holder's Name

Policy Holder's Name Primary

Policy Holder's Name Secondary

Group Number

Group Number Primary

Group Number Secondary

Policy Number

Policy Number Primary

Policy Number Secondary

Effective Date

Effective Date Primary

Effective Date Secondary

I,

Name (copy)

hereby authorize New Edge Orthopedics, LLC to se and/or disclose a copy of my medical records containing individually identifiable health information as described below. I understand that this authorization is voluntary. I 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

FINANCIAL INFORMATION

DISABILITY: There will be a fifteen dollar ($20) charge for each disability form and a seven to ten (7-10) BUSINESS day waiting period for all disability forms.

FAMILY MEDICAL LEAVE ACT FORMS: There is no charge but there is a seven to ten (7-10) BUSINESS day waiting period.

HANDICAP PARKING PERMITS: No charge.

MEDICAL RECORDS COPYING FEES: Payment is due prior to mailing or at the time of pick up.

One dollar ($1) per page for the first ten (10) pages.
Fifty cents ($.50) per page for pages eleven (11) through fifty (50).
Twenty five cents ($.25) per page for pages fifty-one (51) and above.
Five dollars ($5) per CD (X-Ray/MRI/Medical Records)
Five dollars ($5) per page printed (X-Ray/MRI films)
Requests for medical records to be provided within forty eight to seventy two (48-72) hours will be processed with an
additional ten dollar ($10) fee.
Please call our office for specific payment details if the following applies:
- Medicaid patients

Authorization

Patient Signature

Date

Time

Other Authorized Person

Relationship to Patient

Witness Signature

Date

PATIENT FINANCIAL RESPONSIBILITIES

FINANCIAL RESPONSIBILITY: All professional services rendered are charged to the patient and are due at the time of service, unless other arrangements have been made in advance with administration.
Necessary forms will be completed to file for insurance carrier payments.

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 pian, to issue payments directly to New Edge Orthopedics, LLC for services rendered to myself and/or my dependents regardless 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.

I have requested medical services from New Edge Orthopedics, LLC on behalf of myself and/or my dependents, and understand that by making this request, I become fully financially responsible for any and all charges incurred in the course of the treatment authorized.

I further understand that fees are due and payable on the date that services are rendered and agree to pay all such charges incurred in full immediately upon presentation of the appropriate statement. A photocopy of this assignment is to be considered as valid as the original.

PRINT

Patient or Responsible Party

Date

SIGNATURE

Patient or Responsible Party Name

Date

New Edge Orthopedics, LLC Yaser El-Gazzar, M.D.

Full Name

Today’s Date

MI

Age

Date of Birth

Best Contact Phone Number:

Occupation:

How Did you learn about New Edge Orthopedics, LLC? Who Referred you?

Address

Email

MEDICATION

Are you currently taking any medications?

Yes
NO

(If yes, please list below)

Medication Detail

Medication Name

Medication Dosage

Medication Direction

Medication Name

Medication Dosage

Medication Direction

Medication Name

Medication Dosage

Medication Direction

Medication Name

Medication Dosage

Medication Direction

Medication Name

Medication Dosage

Medication Direction

Medication Name

Medication Dosage

Medication Direction

Medication Name

Medication Dosage

Medication Direction

Medication Name

Medication Dosage

Medication Direction

Allergies

MEDICAL HISTORY: Please CHECK any conditions that you have had in the past or have currently

Height

Weight

No Significant Medical History To Report Cardiovascular

High Blood Pressure
High Cholesterol
History of Blood Clot
Atrial Fibrillation

Heart Disease

Respiratory

Asthma &s
COPD
Sleep Apnea

OB/GYN

Possible Pregnancy?

Yes
No

Last Menstrual Period

Menopause?

Yes
No

Gastrointestinal

Esophageal Reflux
Ulcer
Liver Disease
Hepatitis

Other Gastrointestinal Disease

Skin

Psoriasis

Infections / Diseases

Neuro / Psych

Endocrine / Hematologic

History of Cancer:

Yes
No

Other Medical History

Other Medical History Details

Details Cardiac you

SURGICAL HISTORY: Please CHECK all that apply

HISTORY OF SURGERY

Yes
No

ORTHOPEDIC

Shoulder

Rotator Cuff Repair
Shoulder Surgery
Shoulder Replacement
Other

Foot / Ankle

Ankle Surgery
Foot Surgery
Other

FAMILY HISTORY: Please CHECK all that apply

ACTIVITY LEVEL: (Please rate)

INACTIVE (normal activities 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 vigorous exercise and/or athletics weekly)
INTENSE (competitive daily vigorous sports training)

SOCIAL HISTORY: Please CHECK all that apply

Do you smoke?

Current Smoker
Former Smoker
No

How many cigarettes per day?

How many years?

How many cigarettes per day?

How many years?

PAIN LEVEL: Please circle the number that best describes your current pain level on the chart below

**Please use the space below to indicate which body part hurts you that you are referring to above. If more than 1 body part is hurting, please indicate which pain number goes with which body part.

What do you do for work:

How would you describe your work activity? For example, manual labor or desk job?

What sports do you enjoy? Are you in any leagues or organized sports?

1. Have you fallen in the last 6 months?

Yes
No

1. Have you fallen in the last 6 months? (copy)

Yes
No

REVIEW OF SYMPTOMS: Have you experienced any of the following symptoms over the past 6 months?

I CERTIFY THAT THE ABOVE IS CORRECT AND COMPLETE TO THE BEST OF MY KNOWLEDGE.

PATIENT’S SIGNATURE

Date

New Edge Orthopedics, LLC Yaser El-Gazzar, M.D.

Injury Report Form

PATIENT INFORMATION FORM

PERSONAL INFORMATION

PARENT / GUARDIAN / SPOUSE INFORMATION

CONDITION / INJURY INFORMATION

INSURANCE INFORMATION

Privacy Practices

FINANCIAL INFORMATION

Authorization

PATIENT FINANCIAL RESPONSIBILITIES

New Edge Orthopedics, LLC Yaser El-Gazzar, M.D.

MEDICATION

Medication Detail

Allergies

Are you allergic to any of the following MEDICATIONS?

Are you allergic to any of the following NON - MEDICATIONS?

MEDICAL HISTORY: Please CHECK any conditions that you have had in the past or have currently

OB/GYN

Other Medical History

SURGICAL HISTORY: Please CHECK all that apply

ORTHOPEDIC

FAMILY HISTORY: Please CHECK all that apply

SOCIAL HISTORY: Please CHECK all that apply

PAIN LEVEL: Please circle the number that best describes your current pain level on the chart below

REVIEW OF SYMPTOMS: Have you experienced any of the following symptoms over the past 6 months?

I CERTIFY THAT THE ABOVE IS CORRECT AND COMPLETE TO THE BEST OF MY KNOWLEDGE.

Intake Form

New Edge Orthopedics, LLC Yaser El-Gazzar, M.D.

Injury Report Form

PATIENT INFORMATION FORM

PERSONAL INFORMATION

PARENT / GUARDIAN / SPOUSE INFORMATION

CONDITION / INJURY INFORMATION

INSURANCE INFORMATION

Privacy Practices

FINANCIAL INFORMATION

Authorization

PATIENT FINANCIAL RESPONSIBILITIES

New Edge Orthopedics, LLC Yaser El-Gazzar, M.D.

MEDICATION

Medication Detail

Allergies

Are you allergic to any of the following MEDICATIONS?

Are you allergic to any of the following NON - MEDICATIONS?

MEDICAL HISTORY: Please CHECK any conditions that you have had in the past or have currently

OB/GYN

Other Medical History

SURGICAL HISTORY: Please CHECK all that apply

ORTHOPEDIC

FAMILY HISTORY: Please CHECK all that apply

SOCIAL HISTORY: Please CHECK all that apply

PAIN LEVEL: Please circle the number that best describes your current pain level on the chart below

REVIEW OF SYMPTOMS: Have you experienced any of the following symptoms over the past 6 months?

I CERTIFY THAT THE ABOVE IS CORRECT AND COMPLETE TO THE BEST OF MY KNOWLEDGE.

Patients with current appointments

Current Patient with a new problem

Current Patient with a new problem

Current Patient with a new problem