Get Registration Form - The Orthopaedic Group Of San Francisco

Filling out the registration form for The Orthopaedic Group of San Francisco online can streamline your experience and ensure that you provide all necessary information for your appointment. This guide offers step-by-step instructions to assist you in completing the form accurately and efficiently.

Follow the steps to complete the registration form online.

1. Press the ‘Get Form’ button to access the registration form and open it for editing.
2. Begin by filling out the today's date, followed by the name and address of your primary doctor, along with your patient number. Ensure this information is accurate.
3. In the PATIENT INFORMATION section, enter your last name, first name, middle name, home and cell phone numbers. Select your marital status from the listed options and provide your social security number.
4. Fill in your birth date and age, select your sex, and provide your street address, city, state, ZIP code, email, occupation, and employer.
5. Indicate if you have had X-rays or MRIs performed, the date, the location, the area of the examination, and how the injury occurred.
6. Specify your ethnicity from the available options and list your referring physician, along with your dominant hand and date of injury.
7. Indicate how you heard about the practice and provide the name and address of your preferred pharmacy. List your preferred language as well.
8. In the PRIMARY INSURANCE INFORMATION section, fill in the insured or subscriber's name, date of birth, address (if different), phone numbers, insurance company name, subscriber number, policy number, and group number.
9. Identify the patient’s relationship to the subscriber, which may include options such as self, spouse, child, and others. Include the subscriber's social security number.
10. Complete the SECONDARY INSURANCE INFORMATION section if applicable, providing similar details as required in the primary insurance section.
11. If applicable, fill in the INDUSTRIAL INJURIES ONLY section with information such as the name of the industrial carrier, date of injury, claim number, and claims adjuster contact details.
12. Sign and date the statement confirming that the information provided is true and authorize the payment of your insurance benefits to the physician.
13. Fill in the medical history section, detailing any current treatments, surgical history, current medications, known allergies, past orthopaedic injuries, and family disease history.
14. In the social history section, answer questions about smoking and alcohol consumption, including frequency. List activities or sports you enjoy.
15. Use the body outline to mark areas of pain and circle severity levels from no pain to the worst pain.
16. Sign and date the medical authorizations and insurance policy acknowledgment sections, if applicable. Review HIPAA privacy information and provide emergency contact details.
17. Once all sections are completed, save your changes within the form, and you can choose to download, print, or share the completed registration form.

Complete your registration form online today to ensure a smooth experience at The Orthopaedic Group of San Francisco.