New Patient Intake - RegenOrtho Palm Beach

New Patient Consultation Intake Form

Patient Demographics

First Name *

Last Name *

Date of Birth *

Sex *

Male Female

Social Security

Phone Number *

Email Address

Address

City

State

Zip Code

Marital Status

Single Married Divorced Widow

Spouse's Name

Spouse Phone Number

Emergency Contact

Emergency Phone

Relationship to Patient

Employer

Employer Phone

Referred By

Allergies

Other Allergies

Family History

Please indicate if any immediate relatives have had the following conditions.

Condition	Mother	Father
Anesthesia Problems
Arthritis
Cancer
Diabetes
Heart Problems
High Blood Pressure
Kidney Disease
Stroke

Social History

Medical History

Have you ever had any of the following?

If Diabetes, last A1C

Surgical History

Please list any hospitalizations, surgeries, fractures or major illnesses.

Type of Surgery	Year/Date	Doctor	Location

Current Medications

Include over-the-counter medications.

Medication	Dosage

Prescription Policy

Pharmacy Name

Pharmacy Address

Pharmacy Phone

Please acknowledge the following policies:

Do not wait until your last pill to call for a refill. 72-hour turnaround required.
If you have not seen the physician in six months, your refill may be denied.
No controlled substance prescriptions will be called, faxed, or electronically sent after hours or on weekends.
If you are seen in the Emergency Room or by another physician and are prescribed medication, please notify our office immediately.
RegenOrtho Palm Beach reserves the right to request a urine drug screen at any time if you are prescribed controlled substances.
Lost or stolen prescriptions/medications will not be replaced.

I have read and understand the prescription policy outlined above.

HIPAA Compliance & Consent

The Health Insurance Portability and Accountability Act (HIPAA) provides patients with fundamental rights to privacy regarding their protected health information (PHI). RegenOrtho Palm Beach is committed to protecting your medical information and complying with HIPAA regulations.

Consent to Use and Disclose Health Information

By signing this form, I consent to the use and disclosure of my protected health information by RegenOrtho Palm Beach for the purposes of treatment, payment, and healthcare operations. This may include coordination and management of healthcare, communication with other providers, billing and payment, and routine healthcare operations.

Right to Revoke

I understand that I have the right to revoke this consent in writing at any time, except to the extent that RegenOrtho Palm Beach has already taken action based on my prior consent.

Notice of Privacy Practices

I acknowledge that I have received and had an opportunity to review a copy of RegenOrtho Palm Beach's Notice of Privacy Practices..

I have read and agree to the HIPAA Consent and Privacy Practices above.

Authorization for Communication

Individuals we may share your health information with:

Name

Relationship

Name

Relationship

May we leave a message regarding your care on your voicemail?

Yes No

Medical Services Agreement

1. Medical Consent

I hereby consent to medical evaluation and treatment by the providers and staff at RegenOrtho Palm Beach. This may include diagnostic procedures, medical treatments, and other services deemed necessary for my care.

2. Financial Agreement

I understand and agree that all charges for services rendered by RegenOrtho Palm Beach are due at the time of service unless other arrangements have been made in advance.

3. NO-SHOW Fee Agreement

If I fail to show up for a scheduled appointment without providing at least 24 hours' notice, I will be charged a $35.00 no-show fee. This fee must be paid prior to scheduling any future appointments.

4. Late Arrival Policy

There is a 15-minute grace period for scheduled appointments. If I arrive more than 15 minutes past my appointment time, my appointment may be rescheduled at the discretion of the provider.

I acknowledge that I have read, understood, and agree to the Medical Services Agreement.

Consent to Treatment

I voluntarily consent to receive medical care, treatment, and services by the providers and staff at RegenOrtho Palm Beach, including but not limited to physical examinations, diagnostic tests, medical treatments, procedures or therapies, and administration of medications.

I understand that I have the right to ask questions and be informed about the benefits, risks, and alternatives to any recommended treatment. I may refuse any treatment and such refusal will not jeopardize my future care.

I consent to treatment as described above and authorize the medical staff of RegenOrtho Palm Beach to provide evaluation and treatment as deemed necessary.

Injection Consent

Potential risks and side effects of injections (not all-inclusive): pain or discomfort at the injection site, swelling, redness, or bruising, infection, bleeding, allergic reaction, and nerve damage (rare).

I acknowledge that I have discussed the nature, purpose, and potential risks of injections with my provider. I understand that while complications are rare, no guarantees have been made regarding results.

I consent to injections as described above and authorize administration as indicated.

Signature & Submission

By typing your name below, you confirm that all information provided is accurate and complete to the best of your knowledge. You acknowledge that you have read, understood, and agree to all policies and consents outlined in this intake form.

Printed Name *

Date *

Signature (type your full name) *

Relationship to Patient (if applicable)

Witness Name

Thank You!

Your intake form has been submitted successfully. Our office will contact you shortly.

Patient Demographics

Allergies

Family History

Social History

Medical History

Surgical History

Current Medications

Prescription Policy

HIPAA Compliance & Consent

Consent to Use and Disclose Health Information

Right to Revoke

Notice of Privacy Practices

Authorization for Communication

Medical Services Agreement

1. Medical Consent

2. Financial Agreement

3. NO-SHOW Fee Agreement

4. Late Arrival Policy

Consent to Treatment

Injection Consent

Signature & Submission

Thank You!

Quick Links

Our Services

Contact Us

Patient Demographics

Allergies

Family History

Social History

Medical History

Surgical History

Current Medications

Prescription Policy

HIPAA Compliance & Consent

Consent to Use and Disclose Health Information

Right to Revoke

Notice of Privacy Practices

Authorization for Communication

Medical Services Agreement

1. Medical Consent

2. Financial Agreement

3. NO-SHOW Fee Agreement

4. Late Arrival Policy

Consent to Treatment

Injection Consent

Signature & Submission

Thank You!

Quick Links

Our Services

Contact Us

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