PATIENT LAST NAME

FIRST

MIDDLE

MALE

FEMALE

AGE

DATE OF BIRTH

HOME PHONE

Social Security #
(Leave blank until first visit)

MAILING ADDRESS

CELL PHONE

CITY

STATE

ZIP

EMAIL ADDRESS

EMPLOYER

OCCUPATION

EMPLOYER'S ADDRESS

CITY

STATE

ZIP

WORK PHONE

MARITAL STATUS

SPOUSE'S NAME

GUARANTOR

RELATIONSHIP

BIRTHDATE

ADDRESS

CITY

STATE

ZIP

HOME PHONE

EMPLOYER OR SCHOOL

ADDRESS

WORK PHONE

PRIMARY INSURANCE CO.

ADDRESS

SUBSCRIBER NAME

BIRTHDATE

Insurance ID #/ Medicare #

GROUP #

SUBSCRIBER EMPLOYER

ADDRESS

SECONDARY INSURANCE CO.

ADDRESS

SUBSCRIBER NAME

BIRTHDATE

Insurance ID #/ Medicare #

GROUP #

SUBSCRIBER EMPLOYER

ADDRESS

Are you represented by an attorney for any type of personal injury such as: a slip and fall, work related injury, motor vehicle or homeowners claim?

Yes No

ATTORNEY NAME
(If you answered "Yes" to the previous question)

ATTORNEY ADDRESS
(If you answered "Yes" to the previous question)

ATTORNEY PHONE NUMBER
(If you answered "Yes" to the previous question)

NEAREST RELATIVE (not at same address)

ADDRESS

HOME PHONE

REFERRING DOCTOR

PHONE

CHIEF COMPLAINT OR AREA OF BODY INVOLVED

RIGHT

LEFT

DATE OF ACCIDENT OR ONSET OF SYMPTOMS

If an accident, how did it happen?

TIME

MONTH

DAY

YEAR

Auto Motorcycle Sport  Slip & Fall Gradual Onset

If 'Slip & Fall'  - Where?

Were you injured at work or during the course of your employment?

YES  NO

How did the accident occur?

PREVIOUS TREATMENT FOR THIS INJURY?

BY WHOM?

WHERE?

WHEN?

YES  NO

HOW?

ALLERGIES?

TO WHAT?

YES  NO

ARE YOU PRESENTLY UNDER TREATMENT FOR ANY OTHER ILLNESS OR INJURY? (Please Explain)

ARE YOU PREGNANT OR IS THERE ANY CHANCE YOU COULD BE? YES  NO

HOW DID YOU FIND OUT ABOUT SOMERSET ORTHOPEDICS?

Patient assigns to Somerset Orthopedic Associates, P.A. patient’s rights to receive payment from any or all of the patient’s insurers which are due to patient to pay for, or reimburse patient, for services rendered to patient by Somerset Orthopedic Associates, P.A.

PATIENT'S SIGNATURE

DATE

Patient assigns to Somerset Orthopedic Associates, P.A. patient’s right to sue any person or business entity for money damages acccruing from failure to pay Somerset Orthopedic Asssociates, P.A. under any contracts obligating insurance carriers, employers, third party administrators or any other entities to pay for medical services rendered to patient or to adminster the process of payment for medical services rendered to patient.

This assignment includes the prosecution of any claims for payment for medical services which regardless of the tribunal or agency that has jurisdiction over said claim.

PATIENT'S SIGNATURE

DATE

SIGNATURE OF ADDITIONAL RESPONSIBLE PARTY

RELATIONSHIP

DATE

Somerset Orthopedics reserves the exclusive right to designate which of its employees shall perform service.