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Patient Registration
To make your first visit easier Commonwealth Orthopaedic Centers, P.S.C. has simplified your registration process. Please fill in the following information in the form below. You will then be able to print out the form and take it to your first appointment already filled out.

Section 1: Patient Information
Name:  
Date of Birth:
(mm/dd/yyyy)		  
Age:  
Social Security No.:   - -
Sex:  
Marital Status:  
Address:  
City:  
State:  
Zip Code:  
Home Phone:  
Work Phone:  
Cell:  
Do you reside in a nursing home facility or skilled nursing facility or floor?  

  

If "Yes", Where?  
     
Employer/School:  
Occupation:  
Address:  
City:  
State:  
Zip Code:  
Emergency Contact:  
Emergency Contact Phone:  
Section 2: If patient is under 18: (Skip to section 3 if patient is over 18)
Parents/Guardian Name:  
Address:  
City:  
State:  
Zip Code:  
Phone:  
Social Security No.:   - -
Date of Birth:
(mm/dd/yyyy)		  
Employer:  
Address:  
City:  
State:  
Zip Code:  
Work Phone:  
Section 3: Injury Information
Injury Occurred in:  
Date of injury/Onset (mm/dd/yyyy):  
How did injury happen:
(50 Chars Max)		  
Area to be treated:  
Were X-rays taken?:  
Where?:  
Off work due to injury:  
If YES, first date missed (mm/dd/yyyy):  
Section 4: Insurance Information
Section 4a: Primary Insurance
Insurance Name:  
Address:  
City:  
State:  
Zip Code:  
Phone:  
Policy No.:  
Group No.:  
Subscriber Name:  
Social Security:   - -
Date of Birth (mm/dd/yyyy):  
Employer:  
Section 4b: Section 4b. Secondary Insurance (If Applicable)
Insurance Name:  
Address:  
City:  
State:  
Zip Code:  
Phone:  
Policy No.:  
Group No.:  
Subscriber Name:  
Social Security:   - -
Date of Birth (mm/dd/yyyy):  
Employer:  
Section 5: Section 5. Workers' Compensation/Automobile Insurance
Insurance Carrier:  
Address:  
City:  
State:  
Zip Code:  
Phone:  
Fax #:  
Contact Person:  
Claim #:  
State injury occurred:  
If Other, where:  
Section 6: Section 6. Additional Medical Information
Your Family Physician:  
Address:  
Referring Physician:  
Address:  
Current Medications:  
Allergies:  
Preferred Pharmacy:  
Pharmacy Phone:  


*After clicking the "Submit" button you will be presented the filled out form. Please bring all printed forms and the Medical History Form, completed and signed, to your appointment time.

 

 

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Copyright © Commonweath Orthopaedic Centers, P.S.C. Serving Northern Kentucky   All Rights Reserved

Legal Disclaimer:
The information presented in this site is for educational purposes only. It should not be used as a substitute for professional medical advice, or as the basis for medical diagnosis or treatment of a specific condition. Commonwealth Orthopeadics is not liable for any action taken or not taken in reliance on the information presented in this site.


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