Eastside Orthopedics & Sports Medicine

PATIENT REGISTRATION FORM

 

Below is required by Federal Statistics and Administration reporting for medical research purposes


Emergency Contact

Primary insurance Information


Assignment of Benefits: I hereby authorize the release of any medical information necessary to process insurance claims. I authorize direct payment to Bret T. Kean, MD, Paul D. Ruesch, MD, Akash Gupta, MD and Heather Beissinger MS, PA-C and East *

We will not distribute your information to any third party at any time. Our privacy policy can be found at https://www.eosdocs.com/privacy-policy/

Medical History Intake Form

What is your approximate weight and height? *

CURRENT MEDICATIONS:

PAST SURGICAL HISTORY


Social History

REVIEW OF SYSTEMS (Do you currently have or had a history of the following? Please check all that apply

FAMILY HISTORY


I, as the patient, state the information is correct and accurate to the best of my knowledge. *