*WELCOME TO OUR OFFICE*

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1 *WELCOME TO OUR OFFICE* WE FIND THAT COMMUNICATION WITH OUR PATIENTS REGARDING OUR BUISNESS OFFICE POLICIES ASSISTS US IN PROVIDING YOU THE BEST SERVICE. THEREFORE WE HAVE PROVIDED A HIGHLIGHT OF SOME IMPORTANT POINTS. *Please advise us if you change your address, phone number, place of employment, or insurance. *We do not accept responsibility for charges denied as a result of changes in your insurance coverage during the course of your treatment. Denials due to changes in your insurer and/or managed care organization are your financial responsibility. *If we participate with your insurance plan, we will file an insurance claim for you. At the time of your visit, we expect payment for your percentage or portion that is not covered by insurance. *Patients without insurance or patients with insurance plans in which we do not participate are expected to pay for charges at the time of service. *It is your responsibility to obtain referral from your primary care physician for services rendered in our office. Charges which are denied due to lack of referral are your responsibility. *Some insurers normally do not pay for supplies provided by our office. If we inform you that a supply prescribed by your physician will not be covered, we expect payment when you receive the supply. In the event that your insurance company is billed and does not remit payment, you will be billed for the supplies which are not paid. *If you need to cancel or reschedule your appointment, you must do so at least 24 hours before your scheduled office appointment and 48 hours before your scheduled procedure. This notification is necessary so that we may schedule other patients needing immediate appointments. I have read the above business office policy statement. As a patient of Dominion Orthopedic Clinic, LLC, I understand my responsibilities. Patient/Guardian Signature

2 PATIENT REGISTRATION FORM PATIENT INFORMATION Patient Name (Last) (First) (Middle) Also Known as Male Female Marital Status Married Divorced Widowed Legally Separated Single Social Security Number - - of Birth / / PHONE NUMBERS: Home Work Cell Address City State Zip Employment Status: Employed Self Employed Full-time student Part-time student Retired unemployed Employer Occupation Emergency Contact Name Phone Number Relationship Referring Provider Name/Phone # RESPONSIBLE PARTY (Person who carries the insurance policy) Responsible Party Name (Last) (First) Intial SSN: - - Male Female of Birth / / Phone Numbers: Home Work Cell Address: City State Zip Employment status: Employed Self Employed Full-Time Student Part-Time Student Retired Unemployed Employer Employer phone # PRIMARY HEALTH INSURANCE (Provide your insurance card to the front desk at check-in) Name of Insured Patient relationship to Insured Insurance Company/Phone Number ( ) Insurance Company Address Subscriber ID (Policy Number) Group ID Copay amount Effective Termination Insured of Birth / / Insured Social Security Number - - SECONDARY HEALTH INSURANCE: Name of Insured Patient relationship to Insured Insurance Company/Phone Number Insurance Company Address Subscriber ID (Policy Number) Group ID Copay amount Effective Termination Insured of Birth / / Insured Social Security Number - - PLASED READ AND SIGN: I agree that the information supplied on this form is accurate and up-to-date to the best of my knowledge. Patient (or responsible party) Signature WORKER S COMPENSATION Work Compensation injury Yes NO of Injury: / / Employer s Name at the time of injury Address Phone # Adjuster Name and Phone # Insurance Company Name

3 Dominion Orthopaedic Clinic, LLC New Patient Questionnaire : Patient Name: DOB: Age: Primary Care Physician: Referred by: Have you been treated by another physician in our practice? (Please check box): Dr. John Foster III Dr. Eric Steenlage Dr William Sutlive Dr Pinecca Patel Have any family members been treated by Dominion Orthopaedic Clinic? No Yes of Injury: Is your injury work-related? Yes No How did your injury occur? REASON FOR VISIT (Check all that apply.) Location Right Left Both Location Right Left Both Back Neck Shoulder Elbow Wrist Hand Finger Hip Thigh Knee Shin Ankle Foot Toe Other: Please check your dominant hand: Right Left How SEVERE is your pain? (Check one) MILD MODERATE SEVERE Describe the ONSET of your pain: (Check one) Gradual Gradual following an incident at work Sudden Sudden following an incident at work Sudden following a motor vehicle accident How long have you had your pain? (Enter #) (Check one) hours days weeks months years Describe the COURSE of your pain: (Check one) INCREASING DECREASING CONSTANT Describe the PATTERN of your pain: (Check one) INTERMITTENT PERSISTENT What DIAGNOSTIC tests have you had for this problem? (Check one) MRI CT X-RAY What TREATMENTS have you had for this problem? (Check one) NONE INJECTION OCCUPATIONAL THERAPY PHYSICAL THERAPY CHIROPRACTIC CARE

4 Past Surgical History: (list all) SURGERY DATE HOSPITAL 1: 2.: 3.: 4.: Please list your current medications: 1.: ALLERGIES Please check medication allergies and list reactions: NONE PENICILLIN SULFA CODEINE IODINE IVP DYE IBUPROFEN LATEX ERYTHROMYCIN LEVAGUIN DEMEROL OTHER: REACTION: PAST MEDICAL HISTORY Please check all that apply: HYPERTENSION ASTHMA ANEMIC HIV HIGH CHOLESTEROL KIDNEY DISEASE STROKE DIABETES HEPATITIS A B C ULCER (STOMACH) DEPRESSION CANCER RHEUMATOID ARTHRITIS PACEMAKER GOUT OTHER: FAMILY HISTORY Complete all that apply: Medical Problem Family Member Medical Problem Family Member 1. Heart Disease 5. Hypertension 2. Diabetes 6. Kidney Problems 3. Stroke 7. High Cholesterol 4. Bleeding Problems 8. Osteoporosis SOCIAL HISTORY: Smoking: YES NO OCCASIONAL How often? Alcohol: YES NO OCCASIONAL How often? Drugs: YES NO OCCASIONAL How often? VITALS: Weight Height Are you pregnant? Yes No Patient Signature:

5 Medical Release Authorization You are authorized and directed to furnish any and all information requested pertaining to my medical care and treatment to: Dominion Orthopaedic Clinic, LLC John I. Foster, III, M.D., FACS William G. Sutlive, III, M.D Peachtree Dunwoody Road Suite 215 Atlanta, Georgia Phone: Fax: This authorization includes furnishing of the originals or copies of all charts, summaries, test results and all other written memoranda or data including x-rays and photographs. This day of,. Patient s Name of Birth Patient s Signature The Medical Quarters Building 5555 Peachtree Dunwoody Road, Suite 215 Atlanta, GA P: F:

6 PATIENT PAIN MANAGEMENT It is our goal to manage our patient s pain in the healthiest manner. Dr. Foster and Dr. Sutlive s policy regarding pain medicine is as follows: Nonsurgical patients will be given narcotics for 2 to 3 weeks after the onset of the acute phase of their injury or illness. Then non-narcotic measures will be implemented for pain control. Patients will be given strong pain medication when scheduling their surgery. This prescription will be for their use immediately following their surgery. This allows patients the convenience of having their pain medication filled, and readily available to them when returning home after surgery. It will be the patient s responsibility not to lose or use this prescription before surgery. No exceptions will be made if this prescription is lost or used, for writing any additional prescriptions. If pain continues, a lesser strength pain medication will be prescribed. These types of pain medications will be given for 2 to 6 weeks depending on the severity of the surgery. Following these 6 weeks, no other narcotic pain medication will be given. Measures used to decrease pain will include: Physical therapy, icing, rest, NSAIDs, and muscle relaxants. If pain persists following the above, patients will be referred to a pain management specialist. If we determine our patient is obtaining narcotics elsewhere, the patient will not receive any future pain prescriptions. No narcotics will be called in by this practice. NARCOTIC PRESCRIPTIONS MUST BE OBTAINED AT THE TIME YOU ARE SEEING DR. FOSTER OR DR SUTLIVE. John I. Foster, III, M.D., FACS and William G. Sutlive, III, M.D. believe the above policy is only in the best interest of all our patients. Each patient s request will be evaluated individually and professionally. It is our wish that patients not become addicted to narcotic pain medication. I acknowledge the above policy, and understand it in full. Patient Signature 4235 Johns Creek Parkway Suite B Suwanee, GA P: F: The Medical Quarters Building 5555 Peachtree Dunwoody Road, Suite 215 Atlanta, GA P: F:

7 PLEASE READ AND SIGN PATIENT CONSENT FORM I, the undersigned, hereby consent to the following treatment: Administration and performance of all treatments. Administration of any needed anesthetics. Performance of such procedures as may be deemed necessary or advisable in the treatment of this patient. Use of prescribed medication. Performance of diagnostic procedures/tests and cultures. Performance of other medically accepted laboratory tests that may be considered medically necessary or advisable based on the judgment of the attending physician or their assigned designees. I fully understand that this given in advance of any specific diagnosis or treatment. I intend this consent to be continuing in nature even after specific diagnosis has been made and treatment recommended. The consent will remain in full force until revoked in writing. I understand that John I. Foster, III, M.D., FACS and William G. Sutlive, III, M.D. will include consent at satellite offices under common ownership. I, the undersigned, authorize John I. Foster, III, M.D., FACS and William G. Sutlive, III, M.D. to use and disclose my information for the purposes of treatment, payment, and healthcare operations as described in the Notice of Privacy Practices. A photocopy of this consent shall be considered as valid as the original. MEDICARE PATIENTS: I authorize the release of medical information about me to the Social Security Administration or its intermediaries for my Medicare claims. I assign the benefits payable for services to John I. Foster, III, M.D., FACS and William G. Sutlive, III, M.D. I acknowledge that I have been given the Notice of Privacy Practices of John I. Foster, III, M.D., FACS and William G. Sutlive, III, M.D... I understand that if I have questions or complaints that I should contact the Privacy Official. PATIENT INITIAL: I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents. Patient (or Responsible Party) Signature The Medical Quarters Building 5555 Peachtree Dunwoody Road, Suite 215 Atlanta, GA P: F:

8 Cancellation & No Show Policy As our goal is to meet the needs of our patients, we will make every effort to schedule your appointments as efficiently as possible. In return, it is your responsibility to make every effort to keep your scheduled appointments and to arrive promptly at the time instructed. However, we realize that unanticipated events can occur and may prevent you from keeping your appointment. In fairness and consideration to the other patients that need to be seen as soon as possible, we hereby request that you notify our office immediately when you realize you will not be keeping your appointment. As a courtesy, we try to call and confirm your appointment, however if we are unable to call or reach you, please understand that it is your responsibility to remember your appointment dates and times to avoid a missed appointment and a cancellation fee. If you need to cancel or reschedule your appointment, you must do so at least 24 hours before your scheduled office appointment and 48 hours before your scheduled procedure to avoid paying a $50.00 fee. This fee is not covered by your medical insurance or Worker's Compensation benefits. In an effort to see patients promptly at the scheduled time; therefore, this notification of 24 or 48 hours is necessary so that we may schedule other patients needing immediate appointments. As a courtesy, we will give you a reminder call but The cancellation/rescheduling fee must be paid on or before your next scheduled appointment. Thank you for your attention to this matter. Worker s Compensation patients, please note that we will need to notify your adjustor and/or Nurse Case Manager in the event that you cancel within 48 hours of your scheduled procedure. I hereby acknowledge that I have read and understand the above cancellation and no show policy and that I agree to abide by these guidelines. Patient Signature The Medical Quarters Building 5555 Peachtree Dunwoody Road, Suite 215 Atlanta, GA P: F:

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