Patient Forms
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Patient Forms that need to be filled out for Appointments
Please complete steps 1 and 2

1. EMR Link (Patient Health History)
If you are a new patient or have not been seen in our office since January 23, 2012, please fill out the new patient form. This should take you about 20 minutes to complete. This information will automatically be sent to our system once submitted so you do not need to print it out.

2. Privacy Notice (HIPPA Information)
Read, Print optional

 

 

Patient Checklist for an Office Visit

1. Patients having an examination of the Hips or Knees, please bring or wear shorts (without metal) for X-rays and examination. For shoulder and back examinations, please wear a tank top under shirt.

2. If you have had an X-ray or MRI, please bring the CD or films. This is very important!!! X-rays taken at Alexian Brothers, St. Alexius, Sherman, or Northwest Community can be viewed online, but studies taken elsewhere need to be brought in at time of appointment in order to prevent rescheduling of appointments.

3. Photo identification

4. Insurance Card

5. Co Payment

6. Any patient less than 18 years of age must bring an adult who is older than 18 years of age and is either a legal guardian or a letter by the legal guardian authorizing treatment and also a copy of the parent's driver license.

7. Please bring your medication and past medical history list with you to your next appointment.

Medical Records/Authorization to Release Medical Information

Release of Information FROM Core Orthopedics to another facility

Release of Information TO Core Orthopedics from another facility

Please fax all releases to 847-690-1777 Attn: Medical Records

Minor Consent

As the parent if you are unable to attend your child's visit, please read the Minor consent thoroughly and send with your child the day of the appointment.

Consent Form for Minors