DESERT ORTHOPEDICS

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Request Appointment

Although this form is for an appointment request only, your input is important to us and will help us schedule an appointment for you that works best with your schedule. With this information, we will check our availability and contact you within one business day to confirm your appointment.
This request is for non-urgent appointments only. For medical emergencies, please dial 911.
You may also contact Desert Othopedics directly at (541) 388-2333 in Bend or (541) 548-9159 in Redmond, Monday through Friday for assistance with scheduling appointments.

What is the Injury Event Cause?

Patient Information

Patient Name


Age
Home Phone
Employer Phone
Address



Birthday
Sex: Male Female
Employer
Occupation
Primary Physician

Responsible Party (if Different From Patient)

Same as Patient Information
Relationship to Patient
Name


Age
Home Phone
Employer Phone
Address



Birthday
Sex: Male Female
Employer

Personal Medical Insurance

Primary Insurance Name
Policy ID #
Group #
Subscriber Name
Birthdate
Relationship to Patient
Secondary Insurance Name
Policy ID #
Group #
Subscriber Name
Birthdate
Relationship to Patient

Work injury Insurance

Work Comp Insurance
Injured Body Area
Date on Injury
Claim No.
Claim Representative's Name
Claim Representative's Phone
Claim Open: Yes No
Employer at time of accident
Patient's Attorney (if any)
Employer Address

MVA or Liability Medical Insurance

Insurance Name
Policyholder
Insurance Address



Ins. Phone No.
Date of Accident
Claim Number
Patient's Attorney (If Any)

In Case of Emergency

Name of friend or relative not living with you who couid reach you in case of an emergency

Name
Phone

Telephone Contact

Do you have an answering machine: Yes No
May we contact you at work: Yes No
May we leave medical information on the machine: Yes No
May we leave account information on the machine: Yes No

Appointment Details

Primary reason for the appointment
Preference for day/time appointment
If you prefer a specific provider, please enter the provider's name
Do you prefer a provider who is male or female?: Male Female No Preference
Were you referred by a health care provider?: Yes No
If yes, name of the health care provider who referred you
Referring provider specialty
Referring provider city and state

Authorization to release information. Assignment of Insurance Benefits. Agreement/Contract

I hereby authorize Desert Orthopedics to release to the insurance company named above any information acquired in the course of my examination or treatment (if patient is a minor, parent or guardian sign).

I hereby agree to full responsibility for all expenses incurred by or on account of this patient and hereby assign to Desert Orthopedics any and all insurance benefits due me to the full extent of my financial obligation to said doctor.

I understand my insurance coverage is a reletionship between myself and my insurance company and I agree to accept financial responsibility for payment for charges incurred. I understand that I may be billed for uncanceled appointments. In the event of non-payment, I will bear the cost of collection and/or court costs and reasonable legal fees should this be required. I understand the confidentiality policy and credit police of Desert Orthopedics as presented on the reverse side of this form.

OFFICIAL MEDICAL PROVIDER TO THE US SKI AND SNOWBOARD TEAMS