<p> South Shore Orthopedic Associates, P.C.</p><p>PLEASE PRINT PATIENT REGISTRATION</p><p>Patient’s Name ______DOB______/______/______M F</p><p>Social Security Number ______</p><p>Street Address______Apt/Suite______</p><p>City______State______Zip______</p><p>Home Phone ______-______-______Work Phone______-______-_____ Ext______</p><p>Insurance Subscriber’s Name______</p><p>Patient’s Relationship to Subscriber: Self___ Spouse___Dependent Child___ Other____</p><p>How Were You Referred? ______</p><p>GUARANTOR (Insurance Subscriber) INFORMATION</p><p>Guarantor’s Street Address______Apt. Suite______</p><p>City______State______Zip______</p><p>Home Phone ______-______-______Work Phone ______-______-______Ext______</p><p>Subscriber’s Employer______</p><p>Employer’s Address______</p><p>City ______State______Zip______EMERGENCY CONTACT</p><p>Name______</p><p>Relationship to Patient______</p><p>Address______Apt/Suite______</p><p>City______State______Zip ______</p><p>Home Phone______-______-______Work Phone ______-______-______Ext______</p><p>Please Complete if applicable</p><p>WORKERS COMPENSATION</p><p>Carrier______</p><p>Contact ______</p><p>Carrier’s Address______</p><p>City ______State______Zip______</p><p>Injury Date ______-______-______Employer Group:______Claim # ______</p><p>Comments______</p><p>ATTORNEY</p><p>Firm ______Attorney______Address______</p><p>City ______State ______Zip ______</p><p>Comments ______</p><p>MOTOR VEHICLE ACCIDENT</p><p>Auto Insurance Carrier______</p><p>Address______</p><p>City ______State ______Zip______</p><p>Date of Accident______/______/______Policy #______</p><p>Policy Holder______Carrier’s Phone # ______-______- ______</p><p>Physician/Pharmacy Info (IMPORTANT PLEASE COMPLETE)</p><p>Primary Care Physician______Phone #______</p><p>Address______State ______Zip______</p><p>Pharmacy Name______Town______Phone #______</p><p>INSURANCE INFORMATION</p><p>Primary Insurance______</p><p>Address ______</p><p>City ______State ______Zip______Phone #______</p><p>Policy #______Group # ______Name of Policy Holder: ______</p><p>Secondary Insurance ______</p><p>Address ______</p><p>City ______State ______Zip______Phone #______</p><p>Policy #______Group # ______</p><p>Name of Policy Holder: ______</p><p>***PATIENT CONSENT***</p><p>I verify that the above information is accurate and agree to inform South Shore Orthopedic Associates of any changes that may occur as soon as I am aware of the changes.</p><p>AUTHORIZE FOR RELEASE OF INFORMATION TO PAYORS AND/OR CAREGIVERS: I authorize South Shore Orthopedic Associates and any physician giving care to me or my dependent child, to release medical or other information necessary for the (1) completion of insurance claims or receipt of benefits, (2) review of the quality and appropriateness of my care by representatives of external agencies designated by law to conduct such reviews. I understand that South Shore Orthopedic Associates will forward copies of all or part of my medical record to any physician participating in my care and to any facility to which I may be admitted or transferred. If my care is related to an accident at work, I understand my employer’s Worker’s Compensation Carrier will also have access to information contained in my medical record.</p><p>ASSIGNMENT OF BENEFITS: I authorize and request payment of medical benefits to be made directly to this office for services rendered. I UNDERSTAND THAT MY INSURANCE CARRIER MAY PAY LESS THAN THE ACTUAL BILL FOR SERVICES. I AGREE TO BE RESPONSIBLE FOR PAYMENT OF ALL SERVICES rendered on my behalf or my dependents. I understand that my insurance carrier may require me to obtain a referral PRIOR to my visits. I also understand that if I FAIL TO OBTAIN RFEERRALS PRIOR TO MY VISITS, I WILL BE RESPONSIBLE FOR PAYMENT.</p><p>MEDICARE AUTHORIZATION: (Medicare Recipients Only) I certify the information given to me in applying for payment of Medicare benefits under Title XVIII of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Social Security Administration and the Health Care Financing Administration or its intermediaries or carriers any information needed for this or related Medicare claim. I request that the payment of authorized benefits to be made on my behalf to South Shore Orthopedic Associates or any physician providing service during my treatment.</p><p>ACKNOWLEDGE OF RECEIPT-AN IMPORTANT MESSAGE FROM MEDICARE: If I am Medicare eligible, my signature only acknowledges my receipt of this message from South Shore Orthopedic Associates and does not waive any of my rights to request a review or make me liable for any payment.</p><p>SIGNATURE: I have read the information above or have had it read to me. I understand the information and my questions have been answered to my satisfaction. My signature below verifies that I voluntarily consent to the above.</p><p>Signature of Patient (Authorized Representative) Relationship Date</p><p>Witness: ______ORTHOPEDIC HISTORY (Please Complete Both Sides)</p><p>Name: ______Today’s Date: ______/______/______</p><p>SS#: ______Date of Birth: ______/______/______</p><p>Why are you seeing the doctor today? ______</p><p>Current problem is a result of a(n): Check all that apply</p><p> Motor Vehicle Accident  Work Accident  Accidental Injury  Other</p><p>MEDICATIONS</p><p>MEDICATION DOSE REASON FOR MEDICATION SIDE EFFECTS</p><p>ALLERGIES: (Medications, Anesthesia, and/or Adhesive tape) Please list with type of reaction</p><p>REVIEW OF SYSTEMS</p><p>Are you currently having or have you had problems with:</p><p>CIRCLE Describe if Yes</p><p>Arthritis No Yes ______Balance Problems No Yes ______Blackouts/ Fainting No Yes ______Bleeding Problems No Yes ______Cancer No Yes ______Chronic Infections No Yes ______Coronary Disease No Yes ______Diabetes No Yes ______Digestive Disorders No Yes ______Epilepsy No Yes ______Gout No Yes ______Hepatitis No Yes ______High Blood Pressure No Yes ______Immune Deficiency No Yes ______Kidney/Bladder No Yes ______Lungs, Breathing No Yes ______Phlebitis No Yes ______Scoliosis No Yes ______TB No Yes ______</p><p>PAST MEDICAL HISTORY</p><p>Surgeries/Hospitalization Year Complications</p><p>Have you ever had general anesthesia? No Yes Have you had problems with anesthesia? No Yes Describe ______</p><p>FAMILY HISTORY Alive Deceased AGE HEALTH CONDITION/CAUSE OF DEATH</p><p>Grandmother (mom’s) A D______</p><p>Grandfather (mom’s) A D______</p><p>Grandmother (dad’s) A D______</p><p>Grandfather (dad’s) A D______</p><p>Father______A D______</p><p>Mother______A__ D______</p><p>Sister/Brother______A__ D______</p><p>Sister/Brother______A_ D______</p><p>Sister/Brother______A____ D______</p><p>SOCIAL HISTORY</p><p>Age: ______Height: ______Weight:______</p><p>Occupation: ______</p><p>Are you ____Right Handed ____ Left Handed</p><p>Do you live alone? (Circle) No Yes </p><p>Do you exercise?(Circle) No Yes Describe Exercise/Activity ______</p><p>Smoke Currently? (Circle) No Yes #______Packs per day for ______years.</p><p>Drink Alcohol? ____ Daily ____ 1-2x/week ____ 1-2x/month ____ 1-2x/year</p><p>Other habits, please describe ______</p><p>Patient’s Signature ______Date ______/______/______</p><p>Reviewed By ______Date ______/______/______</p>