• Knee Pain Intake Form

    Complete this before your appointment and your provider can be better prepared during their time with you.
  •  - -
    Pick a Date
  • Tell Us About Your Past Health

    Please check all that apply
  • Please list below any serious medical conditions you have had

  • Current Pain Levels

  • Informed Consent and Insurance Information

    Informed consent for treatment/diagnostic Testing

    To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform the doctor's office of any changes in my medical status. I certify that I am the patient or legal guardian of the above listed patient. I authorize this office and its staff to examine and treat my condition as the medical professionals see fit, including having diagnostic x-ray examination if necessary. 

  • Clear
  •  - -
    Pick a Date
  • For Females: Verification of Pregnancy Status

  • **This is to certify that, to the best of my knowledge, I am not pregnant and give my persmission to have diagnostic x-ray if necessary** (if you are unsure of your pregnancy status, it is very important that you inform your care provider prior to any diagnostic imaging.)

  • Clear
  •  - -
    Pick a Date
  • Release of Information

  • This is confidential record of my medical history and pertinent personal information. The doctor/nurse practitioner reserves the right to discuss this information with medical and allied health professionals per this informed consent. Copies of this record can only be released by your written authorization. Copies of this record can only be released by your written authorization. 

  • Clear
  •  - -
    Pick a Date
  • Insurance Information

  • Browse Files
    Cancelof
  • Browse Files
    Cancelof
  • Should be Empty: