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2 Date of Visit: SPINE CENTER NEW PATIENT WORKSHEET OG MR# Patient Full Name: Date of Birth: Age: Who referred you to our office?: Height: Weight: Primary Care Physician?: Reason for Visit Please describe your reason for today s visit: When did your current symptoms begin or injury occur? Are your current symptoms related to an injury? No Yes Please Describe: If your current symptoms are related to an injury, do you have a lawyer? No Have you had this problem before? No Yes Please Describe: Yes How would you describe your pain now? What makes your pain better? Constant Burning Dull Intermittent Sharp Throbbing Nothing Activity Walking Stinging Aching Lying Down Exercise Twisting Ice Sitting Bending Forward Pain is: Equal of both sides Heat Standing Bending Backward Only or worse on the right side Other: Only or worse on the left side Have you had: Inability to urinate Arm or leg weaknesses Mark areas below where you are having PAIN with Loss of balance while walking an X, and NUMBNESS/TINGLING with an O: Falls Front Front Back Are your symptoms getting: Better Worse Staying the Same Right Left Right What is your current work status? Out of Work Light Duties Full Duties Retired Occupation OR previous occupation: List anything else you can not do or have had to change because of your symptoms: Who else have you seen for this problem? What tests have you had for this problem? CT Scan Myelogram EMG or Nerve Conduction Blood Work X Rays MRI Please rate your pain NOW: Where/date: No Worst Pain Ever Have you tried any of the following? Chiropractor Acupuncture Physical Therapy Massage Therapy Please rate your pain AT ITS WORST: What medications have you tried? CIRCLE WHICH WORKED BEST No Worst Pain Ever What makes your pain WORSE? Have you received any injections? No Yes (If Yes, what kind?) All Activity Lifting Coughing Sitting Bending Sneezing Standing Twisting Lying Down Walking Nothing The pain wakes you from sleep Other: MD/PA/NP Signature: Date: Office Use Only: Blood Pressure / Pulse Temperature Rev: 9/11

3 () ("!!$! *+!%% #","!%&-&.$/+$,"! *")0!/1./23$!!(%&-&.$/%!% " 4#(560 /60+! 7689:;<6* '((#"!#"!!(=>(#(">&?&4#' # '((!#&?! ((! # ((! # ((! # " $# (##=$"$"!! &=(4"!! &$!((! &* (# &#=! & # &?(+4"!! &* 4"!! &4"(! (# &#=4"!! &A(((!4"!! &*!# &4"(!4"!! &!4"!! &A!# &B (# &3!# &2A &*4"!! &B4"!! &3((# &2! (3"(( &*!4"!! &#=4"!!! &2!4# &*!! &.C$!

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5 AUTHORIZATION TO RELEASE MEDICAL RECORDS I hereby authorize Macon Orthopaedic and Hand Center, dba OrthoGeorgia to release any information concerning my medical condition necessary during the course of my examination and treatment. I authorize the use of this form on all of my insurance submissions. I authorize payment directly to the physicians and understand that I am responsible for my bill. ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY NOTICE I acknowledge that the OrthoGeorgia Privacy Notice Revision Dated April 13, 2003 has been made available to me. A paper copy of this Notice will be provided at my request. This Notice is also displayed on the OrthoGeorgia website (www.orthoga.org) and in the office of OrthoGeorgia. DIAGNOSTIC STUDIES I understand that OrthoGeorgia can provide services for diagnostic studies and tests. I understand that I have the option of choosing another facility if I so desire. OrthoGeorgia will provide me a list of other facilities at my request. REHABILITATION SERVICES I understand that OrthoGeorgia can provide rehabilitation services at their facility to include physical therapy and occupational therapy. I understand that I have the option of choosing another facility if I so desire. OrthoGeorgia will provide me a list of other facilities at my request. MEDICATION HISTORY AUTHORIZATION I give OrthoGeorgia permission to obtain/retrieve and view my medication history. I understand that this information will be disclosed/divulged as part of my medical record release. I do not give OrthoGeorgia permission to obtain/retrieve and view my medication history. I understand that this information will be disclosed/divulged as part of my medical record release. Patient or Patient Representative Printed Name Personal Representative Relation to Patient Patient or Personal Representative Signature Date

6 Consent to Treatment and Other Acknowledgments By reading and signing this document, I, the undersigned patient (or authorized representative) consent to and authorize the performance of any treatments, examinations, medications, anesthesia, medical services, and surgical or diagnostic procedures (including but not limited to the use of lab and radiographic studies) as ordered or approved by my attending physician(s), or any healthcare professional assigned to my care by my attending physician(s), and I acknowledge and consent to the following: 1. INDEPENDENT CONTRACTORS: OrthoGeorgia may utilize independent contractors for office, outpatient or inpatient treatment/procedures. These include, but are not limited to, surgical assistants, physical therapists, and consulting and referral physicians. Healthcare professionals that are independent contractors are not agents or employees of OrthoGeorgia and are responsible for their own actions. I understand that OrthoGeorgia shall not be liable for the acts or omissions of independent contractors. This Consent to Treatment also applies to any independent contractor utilized by my physician(s). 2. VALUABLES: OrthoGeorgia assumes no responsibility for, and I hereby release OrthoGeorgia from liability for, loss or damage to any of my personal property while on the premises and/or receiving treatment. 3. AUTHORIZATION FOR RELEASE OF INFORMATION AND ASSIGNMENT OF THIRD PARTY PAYMENTS: I hereby expressly authorize OrthoGeorgia and all healthcare professionals providing care to release all necessary information to any insurance company, health plan or other entity (third party payor) which may be responsible for paying for my care. I authorize and direct all payors to pay all benefits due for such care directly to OrthoGeorgia and all professionals (including independent contractors) providing for such care, and I hereby assign such sums to them. I understand this authorization and assignment shall remain valid unless I provide written notice of revocation to OrthoGeorgia and the third party payor signed and dated by me; however, such revocation shall not be effective as to information released and/or charges incurred prior to such revocation. 4. PAYMENT FOR SERVICES: In return for services to be provided by OrthoGeorgia, I promise to pay for services rendered by OrthoGeorgia to me or for my benefit. If the services I receive from OrthoGeorgia are covered by a third party payor, OrthoGeorgia may elect to bill and accept payment from such third party. I will pay the portion of these bills which the third party payor determines are my responsibility. In the case of services which I agree to receive but which are not covered by the third party, I will pay the amount due upon receipt of services. If no third party is involved in paying for my services, I agree to pay in full for such services at the time the services are received. 5. AUTHORIZATION AND RELEASE FOR PHOTOGRAPHS: I authorize and release OrthoGeorgia and its employees and agents to take photographs, videos, x-rays, and/or other photographic, electronic or other images of me and to use them as may be medically appropriate. Such images may be used for educational or other purposes as necessary and appropriate. These images may be maintained as a permanent part of my medical record. I understand and acknowledge that OrthoGeorgia may use cameras for security and patient monitoring, and patient confidentiality will be maintained for all such images. 6. NO GUARANTEE OF RESULTS: OrthoGeorgia physicians and healthcare professionals cannot guarantee any specific result(s) of any examination, treatment, procedure or medical care. I release OrthoGeorgia, its physicians and healthcare professionals from any liability for any accident or injury that is not directly caused by the negligence of OrthoGeorgia or its employees. 7. During the course of my care and treatment, I understand that various types of examinations, tests, diagnostic or treatment procedures ( procedures ) may be necessary. These procedures may be performed by physician(s), nurses, technicians, physician assistants, or other healthcare professionals. While routinely performed without incident, there may be material risks associated with these procedures. If I have any questions concerning these procedures, I will ask my physician(s) to provide me with additional information. I also understand my physician may ask me to sign additional Informed Consent documents relating to specific procedures. 8. I understand that the healthcare professionals involved in my care will rely on my documented medical history, as well as other information provided by me, my immediate family, or others having information about me, in determining whether to perform or recommend procedures. I agree to provide accurate and thorough information regarding my medical history and any conditions or events which may impact medical decision-making. By signing this document, I certify that I have read and understand its contents and that information provided by me is accurate and complete (including insurance information and current eligibility for benefits). A copy of this document may be utilized the same as the original. Date: Patient/Parent/Guardian/Authorized Representative If not signed by the patient, please indicate relationship to the patient on the line below:

7 Permission to Create a Health Exchange record and Share My Medical Information with my Healthcare Providers We are taking part in an exciting program to improve your healthcare and make office visits easier and more convenient. To do this, all of your doctors participating in the Central Georgia Health Network (CGHN) would like your permission to share your Health Information (as defined below) through the Central Georgia Health Exchange electronic medical record program (Health Exchange). This will authorize your CGHN-participating doctors to disclose your Health Information so that it can be shared electronically with other providers of healthcare to you. I acknowledge that I have read the information set forth below and understand the permission I am giving in this document, and have had the opportunity to have my questions answered about the Health Exchange and this permission form. o Yes, I agree to participate in the Central Georgia Health Exchange electronic medical record o No, I do not wish to participate in the Central Georgia Health Exchange electronic medical record at this time Printed Name of Patient Patient Date of Birth Printed Name of Representative Signature of Patient or Representative AUTHORITY OF REPRESENTATIVE: Date Signed I,, do hereby state that I am authorized to sign this permission on behalf of the patient on the following basis (Relationship to Patient): [A signed copy of this permission will be provided to the patient/representative] This authorization will allow your CGHN-participating doctors to disclose your demographic, insurance, and medical information so that it can be shared with other providers of healthcare to you (including doctors, nurses, and other health professionals, as well as hospitals and other healthcare facilities) and CGHN, through the Health Exchange electronic medical record system. Only authorized healthcare providers and their contractors, and others whose job it is to maintain, secure, monitor and evaluate the operation of the information system and quality of care, would be able to access your information. The Health Exchange will allow your providers access to your health information more quickly and accurately than with paper charts. By signing this authorization, I authorize all of my doctors who participate in CGHN to use and disclose my Health Information and to make such Health Information available through the Health Exchange to other healthcare providers who need access to my Health Information for the purposes described in this document. The Health Information may include, but is not limited to the following: Information contained in medical records; physicians records; surgeons records; x-rays, CAT scans, MRI films, photographs, or other radiological, nuclear medicine or radiation therapy films; pathology materials, slides or tissues; laboratory reports; genetic testing results; discharge summaries; progress notes; consultations; prescriptions; records of child abuse, spousal abuse, drug abuse and alcohol abuse; HIV/AIDS and sexually transmitted diseases diagnosis or treatment; physicals and histories; nurses notes; patient intake forms; correspondence; social workers records; insurance records; consents for treatment; and any other documents concerning any treatment, examination, periods of hospitalization, confinement, diagnosis or other information concerning my physical or mental condition. Information disclosed pursuant to this permission may no longer be protected by federal health information privacy laws and may be subject to redisclosure. However, the Health Exchange system incorporates access controls, encryption technology and other security features designed to protect the privacy and security of your Health Information. In addition, access to the Health Exchange will be limited to only those users who have agreed to use the Health Exchange consistent with your permission. Information shared through the Health Exchange will be used and disclosed for the following purposes and disclosures: clinical care; obtaining reimbursement for health care services; for administrative functions related to the provision of and payment for care; quality monitoring and improvement; and administrative management of the Health Exchange and CGHN. You can learn more about the Central Georgia Health Exchange by reading the information booklet, A Guide To The Central Georgia Health Exchange that is available at the CGHE website (https://www.cghe.net) or on request from your healthcare provider s office. I understand that I may withdraw this permission by giving written notice to Administrator, Central Georgia Health Exchange, 111 Perimeter Parkway, Macon, GA Any withdrawal of permission will be effective except to the extent action already has been taken in reliance on this permission. This permission will expire automatically if the Central Georgia Health Exchange program is discontinued. I understand that my eligibility for treatment or any healthcare benefits cannot be conditioned on whether I sign this permission. However, to the extent I have refused permission, I understand that my Health Information will not be available to my other healthcare providers (including, but not limited to, participating Emergency Rooms, Urgent Care Centers, Hospitals, Surgery Centers, and Doctors Offices) through the Central Georgia Health Exchange.

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