Orthopedic / Sports Medicine Intake Form - NovoClinic Cayman Islands

Patient Details

Please fill out all applicable fields.

First Name

Middle Name

Last Name

Birthday (mm/dd/yyyy)

Email

Phone

Gender

Race / Ethnicity (Optional)

Race (Other)

Latino or Hispanic Origin Group

Language(s) spoken in patients home (Optional)

Other Language (Please specify)

Physical Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Is this application for an Adult or Minor?

Parent / Guardian Details

Required if minor or otherwise has a legal guardian

Relationship to Patient

Guardian First Name

Guardian Middle Name

Guardian Last Name

Guardian Date of Birth

Same contact details as Patient?

Yes

No

Parent / Guardian Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Patient Employer (If any - Optional)

Referred By

Preferred Pharmacy

Sports / Activities

Emergency Contact

Please provide the contact details for your Emergency Contact

Same as Parent/Guardian?

Emergency First Name

Emergency Last Name

Relationship to the patient

Emergency Phone Number

Emergency Email

Insurance Information

Please procide us with your insurance details

Name of Policy Holder

Physician Name / GP details

Insurance Provider

Certificate Number

Group Number

Patient Medical Form – Your Symptoms

To be completed by the Patient or parent/guardian/caregiver

Please provide a brief description of your symptoms

Is your pain in the front or back of your body?

Is it on your right or left?

Please describe the area of your body you are experiencing pain?

Please rate your pain on your best days

Please rate your pain on your worst days

What, if anything, makes the pain better?

Patient Medical Form – Your Health

To be completed by the Patient or parent/guardian/caregiver

Are you a tobacco user?

Yes

No

How many per day?

Do you drink alcohol?

Yes

No

How many drinks do you have per day?

List any other ongoing or past medical conditions

Describe any medical conditions in the family

List any surgeries you have done in the past

Allergies

To be completed by the Patient or parent/guardian/caregiver

Do you have any allergies?

Yes

No

List any type of allergy and associated reaction (i.e. Medication, latex, food, etc.)

Allergy	Reaction

Are you currently taking any medication?

Yes

No

Please list all of your medication Below

Medication Name	Dosage

Patient Release Form

I agree to the following:

1. Co-Pays are collected at the time of the visit.

2. I authorize the release of any medical records or other information necessary to process this claim. I understand that all medical records will be stored on a secure, encrypted server for 7 years. I understand that my data is collected, stored and shared as needed and is handled in compliance with the data protection law.

3. I understand that all treatment fees will be billed directly to my insurance company provider. Please note that we charge the SHIC customary health insurance charges.

4. I authorize NovoClinic to verify my health insurance benefits. I will be responsible for all co-pays/co-insurance and deductibles that may apply.

5. I understand that I will be responsible for all rejected amounts billed to my insurance provider for services rendered by the medical practitioners of NovoClinic.

6. I understand that any amounts outstanding for more than 90 days will be send for debt collection through the appropriate channels

7. I grant permission for licensed medical practitioners at NovoClinic to perform such examinations and medical treatments as deemed necessary or advisable for appropriate evaluation and treatment of my condition.

8. I understand that I will be given all available pertinent information prior to treatment being rendered. I will be given the opportunity to ask questions and to have them answered to my satisfaction.

9. I understand that I may decline treatment at any time.

Parent/Guardian Signature: I am a parent or guardian of the patient. I have read and understand this form and have explained the contents to the patient as appropriate. By signing, I agree to this form on my own behalf and on behalf of the patient.

Patient Signature: By checking this box you sign and agree to the above release document. I have read and understand this form. If I have questions, I will ask. By signing, I agree to this form.

I have read and agree to the Terms and Conditions and Privacy Policy