Patient Intake Form

Name*

Date of Birth*

Address*

Street Address Address Line 2 City State ZIP Code

Sex*

Male
Female

Marital Status*

Married
Single
Divorced
Widowed

Cell*

Email*

Social Security Number*

Drivers License Number

Race

Language

Employer

Work Number

Occupation

School You Attend

Emergency Contact*

Emergency Contact Phone*

Relationship to Patient*

Height - Feet*

Height - Inches*

Weight*

Primary Care Doctor

Primary Care Doctor Phone

Pharmacy

Pharmacy Phone

What physician referred you to us? If none, please type none.*

I, being of legal age (18 or older), understand that I am responsible for all accounts with All American Orthopedic including any rendering Physician that may provide services during my visit. I authorize the release of information to my insurance company.

Patient/ Parent/ Legal Guardian Signature*

Date*

Physician Ownership Disclosure Form

During the course of your physician/ patient relationship with Drs Holt, Jaglowski, Higgs, Weinberg, Juarez, Muffoletto or their representatives at All American Orthopedic & Sports Medicine Institute, you may be referred to any of the following: Alliance MRI - 17490 Hwy 3, Webster, TX 77598 * Houston Physicians Hospital - 333 N Texas Ave #1000, Webster, TX 77598

How did you hear about us?

Friend/Family
Physician Referral
Magazine
Commercial
Radio

Any of these facilities may be out of network with your healthcare provider. You have the right to choose alternate healthcare providers. You will not be treated any differently by your Physician, the Physician's staff, or the facility. A list of specific Physician ownership and Physicians immediate family members ownership is available upon request. This information is being provided to you to help you make an informed decision about your healthcare.

Patient Name*

Signature*

Date*

Physician Ownership Disclosure Form

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