Practice Policy Update regarding COVID-19

Intake Form

PERSONAL INFORMATION
Employed Retired Student
Yes No
PARENT / GUARDIAN / SPOUCE INFORMATION

Parent Guardian Spouse
EMERGENCY CONTACT
REFERRAL INFORMATION
My doctor
Online
Friend or family
Other
INSURANCE INFORMATION
Primary Insurance
Secondary insurance/ School insurance/ Motor Vehicle insurance/ any other Medical coverage
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
No Yes
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

Medical History Form

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

PERSONAL INFORMATION
Single Married Divorced Widowed
A New Patient To The Practice An Established Patient To The Practice
MEDICATION

Yes No
Yes No
Yes No
ALLERGIES
Yes No
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

High Blood Pressure High Cholesterol
History of Blood Clot Atrial Fibrillation Other
Atrial Cardiac Stent Bypass Surgery
Pacemaker Heart Murmur Stroke
Mitral Valve Prolapse
Congestive Heart Failure Anemia
Heart Attack
Other
Asthma COPD
History of Blood Clot Sleep Apnea
Other
Osteoarthritis Gout
Osteoporosis Rheumatoid Arthritis
Lupus Psoriatic Arthritis
Other
Esophageal Reflux Ulcer
Liver Disease Hepatitis
Other
Renal / Kidney Disorder Prostate Disorder Urinary Tract Disorder Urinary Incontinence? No Yes  
Psoriasis Other
Lyme Disease MRSA (Drug Resistant Infection) HIV Disease STD
Other
Migraine Headache Epilepsy Seizures Depression Anxiety
Bipolar Disorder Alcohol Dependence
Drug Dependence Dementia
Other
Diabetes Gestational Diabetes HYPO-Thyroidism
HYPER-Thyroidism HIV Infection
History of Cancer :
No Yes  
Other :
Possible Pregnancy? No Yes
Last Menstrual Period:
Menopause? No Yes
Other :
 
SURGICAL HISTORY

Orthopedic:

UPPER EXTREMITY
Arthroscopic surgery
Rotator Cuff Repair
Shoulder replacement
Other
Arthroscopic surgery
Cubital tunnel release
Other
Carpal tunnel surgery
Arthroscopic surgery wrist
Nerve and vessel hand microsurgery
Amputations
Other
LOWER EXTREMITY:
Hip arthroscopy
Hip replacement
Realignment procedure
Other
Knee arthroscopy
ACL reconstruction
ACL repair
Knee replacement
Meniscus or cartilage transplant
Realignment procedure
Other
Ankle arthroscopy
Ankle ligament reconstruction or repair
Podiatric foot surgery
Other foot or ankle surgery
Epidural or any pain management spine injection
Laminectomy
Discectomy
Spinal fusion
Other type of spine surgery

Non-Orthopedic Surgery:

Cataract Surgery
Tonsillectomy
Adenoidectomy
Wisdom Tooth Extraction
Thyroid Surgery
Cardiac Stent Placement
Open Heart: Bypass Surgery
Cardiac Pacemaker
Appendectomy
Gallbladder Surgery
D & C
C-Section
Hysterectomy
Prostate Surgery
Hernia Repair Surgery
Other
No History of Surgery
FAMILY HISTORY
High Blood Pressure
Diabetes Mellitus
High Blood Sugar
DVT/Blood Clot
Bleeding Disorder
Stroke
Asthma
COPD
Osteoarthritis
Osteoporosis
Cancer
High Blood Pressure
Diabetes Mellitus
High Blood Sugar
DVT/Blood Clot
Bleeding Disorder
Stroke
Asthma
COPD
Osteoarthritis
Osteoporosis
Cancer
High Blood Pressure
Diabetes Mellitus
High Blood Sugar
DVT/Blood Clot
Bleeding Disorder
Stroke
Asthma
COPD
Osteoarthritis
Osteoporosis
Cancer
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
Yes No
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?
Recent Illness Recent Weight Gain(lbs)
Recent Weight Loss(lbs) Fever
Chills Neck Pain/Stiffness Cough
Shortness of Breath
Chest Pain or Discomfort Palpitations
Hearburn / Indigestion Nausea
Vomiting Abdominal Pain
Diarrhea Urinary Symptoms Skin Rash
Easy Bleeding Easy Bruising Tendency
Dizziness Motor Disturbances
Sensory Disturbances Joint Pain Stiffness Joint Stiffness Anxiety Depression
Other

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 :


Yes No

Yes No

Yes No
>

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:

  1. Maintaining strict social distancing and mask policy, (Surgical grade masks, gloves, and sanitizer available)
  2. Touch-less temperature checks prior to entry beyond the front desk
  3. COVID-19 screening prior to appt (on our website or via phone interview)
  4. 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
  5. UV-C light air purifiers running full time sanitizing and filtering the air circulated in the office
  6. 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
  7. 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