LAST NAME FIRST NAME MIDDLE NAME PREVIOUS LAST NICKNAME
SOCIAL SECURITY BIRTHDATE SEX
BILLING ADDRESS STREET CITY STATE ZIP CODE
COUNTY RACE LANGUAGE ETHNICITY
MARITAL STATUS PRIMARY CARE PROVIDER
HOME PHONE NUMBER DAY PHONE NUMBER CELL PHONE NUMBER
ALTERNATE PHONE FOR EMERGENCY E-MAIL
PAYER NAME
ADDRESS CITY STATE ZIP CODE
PLAN NUMBER POLICY NUMBER
GROUP NAME GROUP NUMBER EFFECTIVE DATE
SIGNATURE DATE
Patient
Insurance
Financial Policy
1. Fees are due and payable at the time of your appointment. If we are contracted with your insur-ance, you will be billed any remainder after we hear from them. As a courtesy, we accept cash, checks, Visa, Discover, and Master Card.
2. If you have an HMO or PPO insurance with a designated primary care physician, please make
card or information, you will be required to pay the entire fee including any lab services.3. All co-pays must be paid at the time of your service4. Not all services are a covered benefit in all contracts. If you have a question regarding benefits,
insurance policy is a contract between you and your insurance company.5. All services must be paid in full within 30 days after your insurance has paid their portion. If your
visit is due to a Motor Vehicle Accident, payment in full is due at the time of the service. 6. The person who brings a child for care is ultimately responsible for their bill. The physician will
not get involved in court decisions or support disputes.7. Accounts become past due after 30 days. We reserve the right to send an account to collections
if not paid in full8. All returned checks must be paid with cash or money order within 5 working days or they will be
9. 10. All deductibles and co-payments for Obstetric (OB) services must be paid in full by the 7th month
with regular payments due each month by cash, check or credit card.
I hereby acknowledge that I have read, understand, and agree to the terms of this document relating
to insurance coverage and payment of my bill.
PATIENT/GUARDIAN’S SIGNATURE PRINT PATIENT’S NAME & BIRTH DATE DATE
Signature On File
I authorize use of this form on all my insurance submissions. I authorize release of information to all of my insurance companies. I authorize direct payment to The Liberty Clinic. I permit a copy of this authorization to be used in place of the original. I understand I am financially responsible for all
charges whether or not covered by insurance.
SIGNATURE DATE
Patient InformationPATIENT NAME: PREFERRED NAME:
GENDER: MALE FEMALE DOB: / / AGE: SINGLE MARRIED WIDOW
RACE: (CIRCLE ONE) AMERICAN INDIAN ASIAN BLACK NATIVE HAWAIIAN WHITE UNKNOWN
ETHNICITY: (CIRCLE ONE) HISPANIC NON-HISPANIC UNKNOWN/NOT LISTED LANGUAGE:
ADDRESS: CITY: STATE: ZIP:
SSN# / /
HOME PHONE: CELL: EMAIL:
PATIENT’S EMPLOYER: OCCUPATION:
EMPLOYER ADDRESS: PHONE:
SPOUSE NAME: EMPLOYER: OCCUPATION:
EMPLOYER ADDRESS: PHONE:
EMERGENCY CONTACT (RELATIONSHIP): PHONE:
REASON FOR CONSULT: LEFT/RIGHT/BOTH (LIST BODY PARTS)
REFERRED BY: (FIRST AND LAST NAME OF PHYSICIAN OR HOSPITAL)
FAMILY PHYSICIAN: SEND RECORDS TO THIS PROVIDER? YES NO
PRIMARY INSURANCE: ID#:
GROUP# CO-PAY: $
POLICY HOLDER: SSN#: / / DOB:
SECONDARY INSURANCE: ID#:
GROUP#: CO-PAY: $
POLICY HOLDER: SSN#: / / DOB:
IF PATIENT IS A MINOR-PLEASE COMPLETE
PARENT/GUARDIAN: PHONE: WORK:
EMPLOYER:
ADDRESS:
WHO DOES THE MINOR LIVE WITH?
WORK COMP INFO AUTO ACCIDENT INFO OTHER INJURY INFO
DATE OF ACCIDENT: / / SUPERVISOR: PHONE:
BILLING ADDRESS: STATE:
AGENT: INSURANCE: CLAIM#:
ADDRESS:
MEDICAL INSURANCE INFORMATION (GIVE INSURANCE CARD TO RECEPTIONIST)
Santosh George, M.D.Joshua J Niemann, M.D.Ryan R Snyder, M.D.Leslie D. �omas, M.D.Brett L Wilson, PA-C
2521 Glenn Hendren Drive, Suite 204, Liberty, Mo 64068
P 816-781-6066 F 816-792-5130 www. libertyhospital.org
Board Certified Diplomats of the American Board of Orthopaedic Surgery
ORTHOPEDICSURGEONS CLINIC
T H E
An affiliate of Liberty Hospital
TOSC-001 1
LAST NAME FIRST NAME MIDDLE NAME PREVIOUS LAST NICKNAME
SOCIAL SECURITY BIRTHDATE SEX
BILLING ADDRESS STREET CITY STATE ZIP CODE
COUNTY RACE LANGUAGE ETHNICITY
MARITAL STATUS PRIMARY CARE PROVIDER
HOME PHONE NUMBER DAY PHONE NUMBER CELL PHONE NUMBER
ALTERNATE PHONE FOR EMERGENCY E-MAIL
PAYER NAME
ADDRESS CITY STATE ZIP CODE
PLAN NUMBER POLICY NUMBER
GROUP NAME GROUP NUMBER EFFECTIVE DATE
SIGNATURE DATE
Patient
Insurance
Financial Policy
1. Fees are due and payable at the time of your appointment. If we are contracted with your insur-ance, you will be billed any remainder after we hear from them. As a courtesy, we accept cash, checks, Visa, Discover, and Master Card.
2. If you have an HMO or PPO insurance with a designated primary care physician, please make
card or information, you will be required to pay the entire fee including any lab services.3. All co-pays must be paid at the time of your service4. Not all services are a covered benefit in all contracts. If you have a question regarding benefits,
insurance policy is a contract between you and your insurance company.5. All services must be paid in full within 30 days after your insurance has paid their portion. If your
visit is due to a Motor Vehicle Accident, payment in full is due at the time of the service. 6. The person who brings a child for care is ultimately responsible for their bill. The physician will
not get involved in court decisions or support disputes.7. Accounts become past due after 30 days. We reserve the right to send an account to collections
if not paid in full8. All returned checks must be paid with cash or money order within 5 working days or they will be
9. 10. All deductibles and co-payments for Obstetric (OB) services must be paid in full by the 7th month
with regular payments due each month by cash, check or credit card.
I hereby acknowledge that I have read, understand, and agree to the terms of this document relating
to insurance coverage and payment of my bill.
PATIENT/GUARDIAN’S SIGNATURE PRINT PATIENT’S NAME & BIRTH DATE DATE
Signature On File
I authorize use of this form on all my insurance submissions. I authorize release of information to all of my insurance companies. I authorize direct payment to The Liberty Clinic. I permit a copy of this authorization to be used in place of the original. I understand I am financially responsible for all
charges whether or not covered by insurance.
SIGNATURE DATE
Comprehensive Health History
Have you ever, or do you:
SMOKE yes no Packs per day Age quit Any smokers in the home? yes no
SMOKELESS TOBACCO yes no quit How much? Year quit
DRINK ALCOHOL yes no What forms? Quantity Frequency
ILLICIT DRUGS yes no What forms? Quantity Frequency
ALLERGIES (medication & food) No known medication allergies No known food allergies
List all medication and food allergies, please identify reaction
Are you allergic to latex or latex based products?
See attached list
yes no
CAFFEINE USAGE yes no Co�ee Tea Soda Daily Amount
Tape? yes no Iodine? yes no
MEDICATIONS
Medication Dose How often do you take Medication Dose How often do you take
FAMILY HISTORY
Are your parents living? Mother yes no Father yes no Cause of death?
Please list any health conditions/serious illnesses that your mother, father, sister(s) or brother(s) have or have been told they have
had in the past (i.e. diabetes, heart condition, high blood pressure, stroke, high cholesterol, cancer, thyroid, etc.)
Father
Mother
Sister(s)
Brother(s)
PATIENT FULL LEGAL NAME DATE OF BIRTH
Santosh George, M.D.Joshua J Niemann, M.D.Ryan R Snyder, M.D.Leslie D. �omas, M.D.Brett L Wilson, PA-C
2521 Glenn Hendren Drive, Suite 204, Liberty, Mo 64068
P 816-781-6066 F 816-792-5130 www. libertyhospital.org
Board Certified Diplomates of the American Board of Orthopaedic Surgery
ORTHOPEDICSURGEONS CLINIC
T H E
An affiliate of Liberty Hospital
TOSC-001 2
PATIENT PAST SURGICAL
Angioplasty (heart cath) year Cataract extraction year Lasik year
Angio (heart cath) w/stent year Gallbladder surgery year Liver biopsy year
Appendectomy year Colectomy (colon resection) year ORIF (fracture repair) year
Arthroscopy knee year Colostomy year Pacemaker year
Back surgery year Gastric bypass year Small bowel resection year
CABG (heart bypass) year Hernia repair year Thyroidectomy year
Carpal tunnel release year Hip/Knee replacement year Tonsillectomy year
Other
PATIENT PAST SURGICAL Women only
Augmentation mammoplasty (implants) year D & C year Myomectomy (Fibroidectomy) year
Bilateral tubal ligation year Hysterectomy (abdominal) year Reduction mammoplasty year
Breast Biopsy year Hysterectomy (vaginal) year Oopherectomy (ovary removal) year
Cesarean Section year Mastectomy year TAH/BSO year
Other
TOSC-001 3
PATIENT PAST MEDICALAllergies CHF (Conjestive Heart Failure) Immune system disorder
Anemia COPD (Chronic Obstructive Pulmonary Disease) Irritable bowel disease
Angina (chest pain) Coronary artery disease Liver disease
Anxiety Crohn’s disease
Migraine headaches
Arthritis
Depression
Myocardial infarction (heart attack)
Asthma
Diabetes
Osteoarthritis
Atrial fibrillation
Gallbladder Disease
Osteoporosis
Benign Prostatic Hypertrophy
GERD or chronic heartburn
Peptic ulcer disease
Blood clots locationP.E./DVTWhen:
Hepatitis A B C
Renal (kidney) disease
Cancer location
Hyperlipidemia (high cholesterol)
Seizure disorder
Cerebrovascular accident (stroke)
Hypertension (high blood pressure)
Thyroid high low other
Other
Have you ever had General Anesthesia? Any complications? Yes No
Malignant Hyperthermia
MRSA
Fibromyalgia
Blood clotting disorder
Santosh George, M.D.Joshua J Niemann, M.D.Ryan R Snyder, M.D.Leslie D. �omas, M.D.Brett L Wilson, PA-C
2521 Glenn Hendren Drive, Suite 204, Liberty, Mo 64068
P 816-781-6066 F 816-792-5130 www. libertyhospital.org
Board Certified Diplomates of the American Board of Orthopaedic Surgery
ORTHOPEDICSURGEONS CLINIC
T H E
An affiliate of Liberty Hospital
FIRST, MIDDLE, LAST:
HEMATOLOGIC
HemophiliaDeep Vein ThrombosisSickle Cell
Have you ever received a Blood Transfusion?
PATIENT SIGNATURE: DATE/TIME:
Yes No When?
IMMUNOLOGIC
HIV Infection/AIDSLupusImmunosuppressed (on chemo/transplant)Are you on predisone (Deltasone) Yes No
HERNIA
GroinBelly ButtonIncisional
Santosh George, M.D.Joshua J Niemann, M.D.Ryan R Snyder, M.D.Leslie D. �omas, M.D.Brett L Wilson, PA-C
2521 Glenn Hendren Drive, Suite 204, Liberty, Mo 64068
P 816-781-6066 F 816-792-5130 www. libertyhospital.org
Board Certified Diplomates of the American Board of Orthopaedic Surgery
ORTHOPEDICSURGEONS CLINIC
T H E
An affiliate of Liberty Hospital
FIRST, MIDDLE, LAST:
TOSC-001 4
LAST NAME FIRST NAME MIDDLE NAME PREVIOUS LAST NICKNAME
SOCIAL SECURITY BIRTHDATE SEX
BILLING ADDRESS STREET CITY STATE ZIP CODE
COUNTY RACE LANGUAGE ETHNICITY
MARITAL STATUS PRIMARY CARE PROVIDER
HOME PHONE NUMBER DAY PHONE NUMBER CELL PHONE NUMBER
ALTERNATE PHONE FOR EMERGENCY E-MAIL
PAYER NAME
ADDRESS CITY STATE ZIP CODE
PLAN NUMBER POLICY NUMBER
GROUP NAME GROUP NUMBER EFFECTIVE DATE
SIGNATURE DATE
Patient
Insurance
Financial Policy
1. Fees are due and payable at the time of your appointment. If we are contracted with your insur-ance, you will be billed any remainder after we hear from them. As a courtesy, we accept cash, checks, Visa, Discover, and Master Card.
2. If you have an HMO or PPO insurance with a designated primary care physician, please make
card or information, you will be required to pay the entire fee including any lab services.3. All co-pays must be paid at the time of your service4. Not all services are a covered benefit in all contracts. If you have a question regarding benefits,
insurance policy is a contract between you and your insurance company.5. All services must be paid in full within 30 days after your insurance has paid their portion. If your
visit is due to a Motor Vehicle Accident, payment in full is due at the time of the service. 6. The person who brings a child for care is ultimately responsible for their bill. The physician will
not get involved in court decisions or support disputes.7. Accounts become past due after 30 days. We reserve the right to send an account to collections
if not paid in full8. All returned checks must be paid with cash or money order within 5 working days or they will be
9. 10. All deductibles and co-payments for Obstetric (OB) services must be paid in full by the 7th month
with regular payments due each month by cash, check or credit card.
I hereby acknowledge that I have read, understand, and agree to the terms of this document relating
to insurance coverage and payment of my bill.
PATIENT/GUARDIAN’S SIGNATURE PRINT PATIENT’S NAME & BIRTH DATE DATE
Signature On File
I authorize use of this form on all my insurance submissions. I authorize release of information to all of my insurance companies. I authorize direct payment to The Liberty Clinic. I permit a copy of this authorization to be used in place of the original. I understand I am financially responsible for all
charges whether or not covered by insurance.
SIGNATURE DATE
Review of Systems* (check yes or no if you currently are experiencing any of the following):
*Please inform the physician, medical assistant or front desk staffof any other medical conditions or concerns.
SYMPTOM YES NO
JOINT PAINS
JOINT SWELLING
JOINT STIFFNESS
UNSTEADY GAIT
NUMBNESS
TINGLING
UNEXPECTED WEIGHT LOSS
FEVER
CHILLS
POOR HEALING WOUNDS
SCARRING / KELOIDS
EASY BLEEDING
Alerts* (check yes or no for the following):
ALERT YES NO
PACEMAKER
BLOOD THINNER
DEFIBRILLATOR
PREMEDICATION PRIOR TO PROCEDURES
RHEUMATOID ARTHRITIS
RSD (REFLEX SYMPATHETIC DYSTROPHY)
ALLERGY TO SHELLFISH OR IODINE
ALLERGY TO LATEX
ALLERGY TO ADHESIVE
PAIN MANAGEMENT TREATMENT
FIRST, MIDDLE, LAST:
Santosh George, M.D.Joshua J Niemann, M.D.Ryan R Snyder, M.D.Leslie D. �omas, M.D.Brett L Wilson, PA-C
2521 Glenn Hendren Drive, Suite 204, Liberty, Mo 64068
P 816-781-6066 F 816-792-5130 www. libertyhospital.org
Board Certified Diplomates of the American Board of Orthopaedic Surgery
ORTHOPEDICSURGEONS CLINIC
T H E
An affiliate of Liberty Hospital
TOSC-001 5
Santosh George, M.D.Joshua J. Niemann, M.D.Ryan R. Snyder, M.D.Leslie D. �omas, M.D.Brett L. Wilson, PA-C
2521 Glenn Hendren Drive, Suite 204, Liberty, Mo 64068
P 816-781-6066 F 816-792-5130 www. libertyhospital.org
Board Certified Diplomates of the American Board of Orthopaedic Surgery
ORTHOPEDICSURGEONS CLINIC
T H E
An affiliate of Liberty Hospital
TOSC-001 6
Patient Name
Adults I hereby give permission for the following individual(s) to pick up my prescription and / or other documents in my absence. To ensure proper handling of all controlled substances, I understand they will be required to show proper photo identification each time.
1.
2.
3.
4.
PHARMACY INFORMATION IN CASE A PHYSICIAN CAN PRESCRIBE THROUGH THIS AVENUE
PHARMACY NAME:
PHONE:
LOCATION:
No one other than myself (patient) has permission to pick up my prescriptions and /or other articles in my absence.
Date of Birth
SIGNATURE DATE
This form does not authorize releasing copies of my medical records.To the following people who are involved with my healthcare and/or payment information: (check all that apply and list names and telephone numbers) Spouse_________________________________________ Phone:__________________ Friend____________________________________________ Phone:__________________ Child(ren)_________________________________________ Phone:__________________ Other_____________________________________________ Phone:__________________ Do not release my information to anyone.I hereby allow The Orthopedic Surgeons Clinic to disclose the following information. (check all that apply) Appointment times and dates Medical information, including my symptoms, diagnosis, medications and treatment plan Tests that have been performed Test results Billing/payment information Other health information (describe)_____________________________________________
Can confidential messages (i.e. appointment information, prescription information, test results) be left on your answering machine or voicemail? (check how you wish to receive messages, and provide the phone number) No, DO NOT leave any messages Yes, at home, cell phone or work: Home Phone:__________________Cell Phone:__________________Work Phone:________________ Yes, only at home Home Phone:_______________________________ Yes, only on cell phone Cell Phone:_____________________________
I understand that in certain situations The Orthopedic Surgeons Clinic may speak to other individuals who are involved in my care or payment of that care, if permitted by law, that may not be identified on this form.
I understand that I have the right to revoke (stop) my permission at any time.
Patient Name (please print):_____________________________________ Date of birth:______________
Patient/Guardian Signature:_______________________________________Date:___________________
If patient is a minor, please complete the following information:Mother’s name/contact number:__________________________________________________________Father’s name/contact number:___________________________________________________________
Permission to Disclose Information to �ose Involved in My Care
Santosh George, M.D.Joshua J Niemann, M.D.Ryan R Snyder, M.D.Leslie D. �omas, M.D.Brett L Wilson, PA-C
2521 Glenn Hendren Drive, Suite 204, Liberty, Mo 64068
P 816-781-6066 F 816-792-5130 www. libertyhospital.org
Board Certified Diplomates of the American Board of Orthopaedic Surgery
ORTHOPEDICSURGEONS CLINIC
T H E
An affiliate of Liberty Hospital
TOSC-002
Permission to Disclose Information to Those Involved in My Care
I hereby allow The Orthopedic Surgeons Clinic to disclose the following Protected Health Information to the following people that are involved with my healthcare or payment (please mark each that you allow):
o Appointment times and dates o Tests that have been performed o Test results o Billing/payment information o Other health information
To the following people who are involved with my healthcare or payment information: (please mark all who apply and list his/her names and telephone numbers)
o Spouse________________________________________________ Phone:________________________________ o Friend_________________________________________________Phone:________________________________ o Child(ren)____________________________________________ Phone:________________________________ o Other__________________________________________________Phone:________________________________
May a con�idential message (i.e. appointment information, prescription information, test results) be left on your answering machine or voicemail (please circle how you wish to receive messages)?
Yes, at home, cell phone or work Yes, only at home Yes, only on cell phone No, DO NOT leave any messages Patient Name (please print):_____________________________________________Date:_________________ Patient/Guardian Signature:_____________________________________________ Date:__________________ If patient is a minor, please complete the following information: Mother’s name/contact number:_______________________________________________________________ Father’s name/contact number:________________________________________________________________
Santosh George, M.D.Joshua J Niemann, M.D.Ryan R Snyder, M.D.Leslie D. �omas, M.D.Brett L Wilson, PA-C
2521 Glenn Hendren Drive, Suite 204, Liberty, Mo 64068
P 816-781-6066 F 816-792-5130 www. libertyhospital.org
Board Certified Diplomates of the American Board of Orthopaedic Surgery
ORTHOPEDICSURGEONS CLINIC
T H E
An affiliate of Liberty Hospital
TOSC-005
Financial Policy
1. Fees are due and payable at the time of your appointment. If we are contracted with your insur-ance, you will be billed any remainder after we hear from them. As a courtesy, we accept cash, checks, Visa, Discover, and Master Card.
2. If you have an HMO or PPO insurance with a designated primary care physician, please make
card or information, you will be required to pay the entire fee including any lab services.3. All co-pays must be paid at the time of your service4. Not all services are a covered benefit in all contracts. If you have a question regarding benefits,
insurance policy is a contract between you and your insurance company.5. All services must be paid in full within 30 days after your insurance has paid their portion. If your
visit is due to a Motor Vehicle Accident, payment in full is due at the time of the service. 6. The person who brings a child for care is ultimately responsible for their bill. The physician will
not get involved in court decisions or support disputes.7. Accounts become past due after 30 days. We reserve the right to send an account to collections
if not paid in full8. All returned checks must be paid with cash or money order within 5 working days or they will be
9. 10. All deductibles and co-payments for Obstetric (OB) services must be paid in full by the 7th month
with regular payments due each month by cash, check or credit card.
I hereby acknowledge that I have read, understand, and agree to the terms of this document relating
to insurance coverage and payment of my bill.
PATIENT/GUARDIAN’S SIGNATURE PRINT PATIENT’S NAME & BIRTH DATE DATE
Signature On File
I authorize use of this form on all my insurance submissions. I authorize release of information to all of my insurance companies. I authorize direct payment to The Orthopedic Surgeons Clinic. I permit a copy of this authorization to be used in place of the original. I understand I am financially responsible for all charges whether or not covered by insurance.
SIGNATURE DATE
Santosh George, M.D.Joshua J Niemann, M.D.Ryan R Snyder, M.D.Leslie D. �omas, M.D.Brett L Wilson, PA-C
2521 Glenn Hendren Drive, Suite 204, Liberty, Mo 64068
P 816-781-6066 F 816-792-5130 www. libertyhospital.org
Board Certified Diplomates of the American Board of Orthopaedic Surgery
ORTHOPEDICSURGEONS CLINIC
T H E
An affiliate of Liberty Hospital
TOSC-004