3. Your copayment is expected at the time of visit. We accept cash, checks, Visa, MasterCard and Discover. We do not accept American Express.

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We would like to welcome you as a patient and thank you for choosing Central Virginia

Orthopaedics & Sports Medicine to provide your orthopaedic needs. It is our mission to

provide you the highest level of care.

For your visit, please bring with you to your appointment:

1. Your insurance card(s).

2. Valid photo identification: Driver’s license, ID card, school ID card with a

photograph, U.S. Military card. All forms of identification must not be expired.

2. If your insurance requires a referral, you must have had it faxed to

our office at or bring with you to the appointment. If you do not have

it, you will need to reschedule your appointment

3. Your copayment is expected at the time of visit. We accept cash, checks, Visa,

MasterCard and Discover. We do not accept

American Express.

4. Please bring the completed patient registration packet along with a

list of medications you are currently taking. Please ensure all forms

are signed and dated.

5. If you have power of attorney or custody, please bring all documentation.

6. Any medical records, X-ray’s, MRIs, films etc with reports.

Thank you

Central Virginia Orthopaedics & Sports Medicine

Fredericksburg Location Stafford Location

501 Park Hill Drive 450 Garrisonville Road, Suite 101

Fredericksburg, Virginia 22401 Stafford, Virginia 22554

Phone (540) 372-6737 Phone ( 540) 659-4555

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Central Virginia

Orthopaedics & Sports Medicine

www.CVOSM.net

Patient information:

Full legal name: Home phone:

( ) Cell phone: ( ) Date of birth: SSN:

- - Age:  Male Gender:  Female

Employer: Employer Address: Phone:

( ) Occupation: Ethnicity: Hispanic or Latino Not Hispanic or Latino Refused Race: Amer. Indian or Alaska Native

Asian Black White More than one race Native Hawaiian or other Pacific Islander Refused

Preferred Language:

Patient Address

Physical address: REQUIRED City: State: Zip code:

Mailing Address or P.O Box: City: State: Zip code :

Spouse Information:

Full legal name: Home phone:

( ) Cell phone: ( ) Date of birth: SSN:

- - Address if different than above: Gender: Male Female

Spouse Employer: Employer Address: Phone:

( ) If the patient is a minor under age 18:

Father’s full name: Father’s SSN:

- - Father’s DOB: Father’s phone: ( )

Address (IF DIFFERENT THAT PATIENT): Cell phone:

( )

Father’s Employer: Employer’s Address: Work Phone:

( ) Mother’s full name: Mother’s SSN:

- -

Mother’s DOB: Mother’s phone: ( )

Address(IF DIFFERENT THAT PATIENT): Cell phone:

( )

Mother’s Employer: Employer’s Address: Work Phone:

( ) Insurance Information:

Primary Insurance Carrier: Subscriber/Policy Holder Name: Relationship to the patient: Secondary Insurance Carrier: Subscriber/Policy Holder Name: Relationship to the patient:

SSN: DOB: Phone:

( ) Address :

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NEW

NEW PATIENT/NEW PROBLEM MEDICAL HISTORY DATE: ___________

Name: __________________________________________ DOB:_______________ Age: ____________ All fields required Are you left handed or right handed? □ Left or □Right

Why are you seeing the doctor today?

HT:_____ WT:_____ BP:_____P:______

LOCATION: □ Left or □Right

_____NECK _____ UPPER BACK _____LOWER BACK _____PELVIS _____SHOULDER

_____ ELBOW _____WRIST _____HAND _____HIP _____KNEE

_____ ANKLE _____FOOT Other area of the body: _______________________________________

ONSET/TIMING: My condition today is:

Injury (Date occurred: ___________ )

Chronic

Recurrent

Non injury (describe) ______________________________________________________________________

DURATION:

How

long has this been a problem? __________________________________________________

CONTEXT: If injury, how did it occur?

Sports

Motor vehicle accident

Work related injury

Fall

Describe injury: _______________________________________________________________________ _________________________________________________________________________________________________

MY CONDITION CAN BE DESCRIBED AS:

QUALITY:

SHARP

DULL

ACHING

THROBBING

OTHER _______________________________________

SEVERITY:

MILD

MODERATE

SEVERE (0-10) ___________________

DURATION LASTS FOR:

MINUTES

HOURS

CONSTANT

TIMING: My condition occurs:

W/EXERCISE OR ACTIVITY

AT REST

NIGHTTIME

SITTING

STANDING

CONTEXT: My condition is getting:

WORSE

STABLE

IMPROVING

RECURRING

MODIFYING FACTORS:

My condition is relieved by: _______________________________________________________________________________________________ My condition is aggravated by: ______________________________________________________________________________________________

ASSOCIATED SYMPTOMS:

My condition has the following signs and symptoms:

SWELLING

BRUISING

REDNESS

FEVER

CHILLS

NUMBNESS

TINGLING

LIMB FEELS COLD

OTHER: ___________________________________________

WHAT TYPES OF TREATMENT HAVE YOU HAD FOR THIS PROBLEM?

_____ANTI-INFLAMMATORY MEDICATIONS _____SURGERY _____CORTISONE INJECTIONS _____NO TREATMENT

_____PHYSICAL THERAPY _____OTHER

HOW WERE YOU REFERRED TO US?

_____PRIMARY CARE DR. _____________________________ _____ATHLETIC TRAINER______________________________ _____EMERGENCY ROOM_____________________________ _____INTERNET

_____OTHER ___________________________________________________________________________________________________ HAS ANOTHER PHYSICIAN TREATED YOU FOR THIS PROBLEM:

YES

NO

PHYSICIAN /PA/NURSE PRACTITIONER NAME: _______________________________________________________________ FACILITY: _________________________________________________________________________________________________ STUDIES PERFORMED?:

X-rays

MRI

CT Scan

Ultrasound

Bone Scan

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MEDICAL HISTORY

DATE: _________

NAME: _________________________________________AGE: _______________

PAST MEDICAL HISTORY:

(Check all that apply)

CANCERType:______________________________ TREATMENT: ______________________________________________

CANCER DISEASE STATE:

CANCER ACTIVE

CANCER CURED

CANCER IN REMISSION

MUSCULAR DYSTROPY

MULTIPLE SCLEROSIS

POLIO

ANXIETY

ASTHMA

COPD

DEPRRESSION

DIABETES

GOUT

HEPATITIS

ALCOHOLISM

HYPOTHRYROID

HYPERTHYROID

STROKE

KIDNEY STONES

LIVER DISEASE

MIGRAINES

KIDNEY DISEASE

ANEMIA

PHEBITIS

AIDS

HIV POSITIVE

BLEEDING DISORDERS

If under 18, Childhood immunizations up to date?

Yes

No Tetanus current?

Yes

No

HEART DISEASE:

(Check all that apply)

ATRIAL FIBRILLATION

CONGESTIVE HEART FAILURE

HYPERTENSION

ELEVATED CHOLESTEROL

IRREGULAR HEART RHYTHM

HEART ATTACK

CARDIAC BYPASS SURGERY

CARDIAC CATHETERIZATION

PACEMAKER PLACEMENT OTHER MEDICAL CONDITIONS: ___________________________________________________________________

PAST SURGICAL HISTORY:

(Please include specific body part)

TYPE OF SURGERY YEAR TYPE OF SURGERY YEAR

MEDICATIONS:

See attached list (list prescription and over the counter)

Name of Medication Dose/ Frequency Reason

DRUG ALLERGIES

:

No Allergies

Allergies Reaction: (Rash, swelling, stomach upset, etc.)

FAMILY HISTORY:

M-Mother F-Father S-Sibling GM-Grandmother GF-Grandfather YES NO Relative Disease state YES NO Relative Disease state

STROKE CANCER

HEART TROUBLE BLEEDING DISORDERS

HIGH BLOOD PRESSURE MENTAL ILLNESS

DIABETES ALCOLOHOLISM

ARTHRITIS KIDNEY PROBLEMS

SEIZURES OTHER:

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MEDICAL HISTORY DATE: ______________________

NAME: __________________________________________________________AGE: __________________ SOCIAL HISTORY

Marital Status:

Married

Single

Separated

Divorced

Widowed Could you be pregnant?:

Yes

No

Do you smoke cigarettes?

Yes

No How many per: day? ______ How many years?_____ Smokeless tobacco?

Yes

No How many cans per week? ____ How long? ________

Did you quit?

Yes, When? _____

No

Do you use alcohol?

Yes

No How many per: Day ____Week_____ Month ______

Recreational Drug Use

:

Yes

No If yes, please explain_________________________________ Employment Status:

Student

Employed

Unemployed

Homemaker

Retired

Job Description: _________________________________________________________________________J

REVIEW OF SYSTEMS (Please answer yes or no in each box)

GENERAL HEALTH

HEAD AND NECK

RESPIRATORY

YES NO YES NO YES NO

FEVER HEADACHES CHRONIC COUGH

CHILLS BLURRED VISION BLOODY SPUTUM

FATIGUE SLEEP APNEA WHEEZING

NIGHT SWEATS HEARING LOSS DIFFICULTY SWALLOWING

CARDIAC

MUSCULOSKELETAL

PSYCHIATRIC

SWELLING EXTREMITIES BACK PAIN ANXIETY

SHORTNESS OF BREATH JOINT STIFFNESS DEPRESSION

CHEST PAIN-AT REST JOINT PAIN PANIC ATTACKS

CHEST PAIN-W/ACTIVITY FOCAL WEAKNESS INDULGENCE

PALPITATIONS EATING DISORDER

NECK

GASTROINTESTINAL

ENDOCRINE

PAIN CONSTIPATION APPETITE CHANGES

STIFFNESS BLOOD IN STOOL EXCESSIVE THIRST

SWOLLEN GLANDS DARK , TARRY, STOOL EXCESSIVE URINATION

NEUROLOGICAL

SKIN

HEMATOLOGY

DIZZINESS RASH EASY BRUISING

SEIZURES BRUISING FREQUENT NOSE BLEEDS

FOCAL WEAKNESS ULCERS ENLARGED LYMPH

NODES

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Patient Name______________________________________________ Date of Birth _____________________ NOTICE OF PRIVACY PRACTICES

The office of Central Virginia Orthopaedics & Sports Medicine maintains protocols to ensure the security and confidentiality of your personal information. We have physical security in our building, passwords to protect databases, compliance audits and virus/intrusion detection software. Within our practice, access to your information is limited to those who need it to perform their jobs.

A NOTICE OF PRIVACY POLICIES BROCHURE will be given to every new patient at the time of his or her initial visit. You have a right to:

Inspect and obtain a copy of your health record as provided by state law. Amend your health record as provided by state law.

Obtain an accounting of disclosures of your health information as provided by state law.

Request confidential communications of your health information and restrict certain uses and disclosures of your health information (we are not required by law to agree to a requested restriction).

Central Virginia Orthopaedics & Sports Medicine is permitted to use or disclose health information without the individual’s written authorization in certain circumstances. Two examples would be for public health

requirements or court orders.

Central Virginia Orthopaedics & Sports Medicine will not make any other use or disclosure of a patient’s protected health information without the individual’s written authorization. Such authorization may be revoked at any time. Revocation must be in writing.

If you have any questions and would like additional information, contact our privacy officer at 540-372-6737. If you believe your privacy rights have been violated, you can file a complaint with the privacy officer by phone or in writing at Central Virginia Orthopaedics & Sports Medicine, Privacy Officer, 501 Park Hill Drive,

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CENTRAL VIRGINIA ORTHOPAEDICS & SPORTS MEDICINE, P.C.

Patient Name ______________________ Date of Birth _____________ SS# _______________

Authorization to treat: I hereby grant permission to the physicians and staff of Central Virginia Orthopaedics & Sports

Medicine, P.C. to perform any necessary procedures to treat the medical condition(s) for which I am seeking assistance. I understand that, except in any emergency situation, the staff will discuss with me my treatment options and that I will have the opportunity to accept or refuse specific treatments at that time.

Authorization to release information: I hereby authorize any holder of medical information about me sent to my

insurance carrier, sponsoring agency, Social Security Administration and its intermediaries or carriers, when relevant, any such information that is requested by them needed for the processing of insurance benefit claims. I HAVE BEEN PRESENTED WITH A COPY OF THE NOTICE OF PRIVACY PRACTICES AS DISCLOSED BY LAW, OUTLINING MY RIGHTS REGARDING MY HEALTH INFORMATION.

Assignment of benefits: I certify that the information I have given is correct. I hereby authorize payment to Central

Virginia Orthopaedics & Sports Medicine, P.C. of the benefits payable to me and to my physician(s). In applying for payment under Title XVIII of the Social Security Act, I request payment of authorized benefits be made on my behalf to those who accept this assignment. Even though Central Virginia Orthopaedics & Sports Medicine, P.C. accepts

assignment of insurance company payments, insurance carriers occasionally send payment checks to the patient for services rendered by the physician. I agree to forward any such payments I receive to Central Virginia Orthopaedics & Sports Medicine, P.C. as soon as I receive them.

Charges for services: The charges for the Central Virginia Orthopaedics & Sports Medicine, P.C. are for the

physician’s professional fees and services. These charges do not include Surgery Center or hospital facility fees. The facility will be billed separately by the facility.

Payment for services: As a courtesy to you, we will file claims with your insurance company. Monthly statements are

mailed to patients only if they are responsible for some portion of the bill. Patients who have no insurance coverage should be aware that payment for service is due on the day you are seen. A discount will be given for full payment on the day of your visit. We accept payment by Visa, MasterCard, Discover, cash and check.

Patient responsibility for payment: I understand that my insurance coverage is a contract between my insurance carrier

and me, NOT between the insurance carrier and Central Virginia Orthopaedics & Sports Medicine, P.C. Ultimately, all fees are my responsibility. Should timely payments not be made on my account, I authorize Central Virginia

Orthopaedics & Sports Medicine, P.C. to retain the services of an attorney or collection agency to assist with the collection. Any expenses incurred by Central Virginia Orthopaedics & Sports Medicine, P.C. for such action shall become an additional liability for which I assume responsibility. There will be a $50.00 charge for returned checks. If at any time, should your insurance information change or we need to bill another carrier, worker’s compensation or new personal insurance, it is your responsibility to furnish the billing information. If you do not furnish this information within 30 days of the initial visit to be billed, any/and all charges will be your responsibility.

I agree and understand:

___________________________________________ _______________________________ Patient or Parent/Guardian Signature Date

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AUTHORIZATION FORM FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION

In order for Central Virginia Orthopaedics & Sports Medicine to disclose Protected Health Information to someone other than you, you must complete this authorization.

__________________________________________ ______________________

Name of Patient (Please Print) Date of Birth

I authorize Central Virginia Orthopaedics & Sports Medicine to disclose information on my health care to the following person(s)

( ) Spouse________________________________

( ) Other (please identify) Telephone Number:

_______________________________________ _____________________________ _______________________________________ _____________________________ _______________________________________ _____________________________ _______________________________________ _____________________________ This authorization is valid until:

( ) _________________________date/event ( ) One year from date I sign this form ( ) Indefinitely

( ) At this time, I do not want my personal health information disclosed to anyone

I have the right to revoke this form at any time by submitting a cancellation authorization in writing to Central Virginia Orthopaedics & Sports Medicine.

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