Optimotion Orthopaedic staff

1 STEVE V. NGUYEN, MD / DAVID PADDEN, MD JEAN FAIRCHILD, PA / AMANDA ROGAN, PA 5979 VINELAND RD. SUITE 101. ORLANDO, FL 32819 PHONE: 407 355 3120 / FAX: 407 355 3119 _____ _____ _____ Dear Sir/Madame In order for our office to prepare for your visit, please fill out every page of this packet . Fax the packet to our office at 407-355- 3119 ONE WEEK PRIOR TO APPOINTMENT OR Mail packet to 5979 Vineland Rd. Suite 101 Orlando Florida 32819 10 DAYS PRIOR TO APPOINTMENT Our office will send you email/text messages regarding your appointment date and time. Optimotion Orthopaedic staff Optimotion Orthopaedics Dr. Steve V Nguyen, / Dr. David A Padden, 5979 Vineland Rd.

2 Suite 101 Orlando, FL 32819 Phone: (407) 355 3120 / Fax: (407) 355 3119 Appoint Date: Appoint Time: Appoint Location: PATIENT REGISTRATION FORM PREFERRED METHOD OF COMMUNICATION Referred by: Friend Family Physician: _____ Other: _____ PATIENT INFORMATION First Name: Middle: Last Name: Address: SSN: Date of Birth: City, State, Zip: Home Phone: Cell Phone: Work Phone: Email Address: Gender: Race: Ethnicity: First Language: Marital Status: Occupation: Employer: Phone: Employer Address Line: Employer City, State, Zip: Primary Care Physician: PCP Phone: EMERGENCY CONTACT/SPOUSE/GUARDIAN/SIGNIFIANT OTHER First Name: Middle: Last Name: Address: City, State, Zip: Home Phone: Cell phone: Work Phone: Employer: Employer Phone: Employer Address Line: Employer City State, Zip: PRIMARY INSURANCE INFORMATION Primary Insurance: Policy Number: Policy Holder s Name: Mailing Address Line: City, State, Zip: Holder s DOB: Holder s Phone: Group Number: SECONDARY INSURANCE INFORMATION Secondary Insurance: Policy Number: Policy Holder s Name: Mailing Address Line: City, State, Zip: Holder s DOB: Holder s Phone: Group Number: FINANCIAL RESPONSIBILITY Person Financially Responsible for Balance Not Covered by Insurance.

3 Patient Spouse Parent Guardian Name: _____ Phone: _____ Address: _____ _____ Optimotion Orthopaedics First Name: Dr. Steve V. Nguyen, Last Name: Dr. David A. Padden, Date of Birth: CONSENT TO EXAMINATION AND TREATMENT INSURANCE ASSIGNMENT AND RECORDS AUTHORIZATION I hereby consent to examination and treatment as deemed necessary by and its physicians. I Hereby authorize Steven V Nguyen , David A. Padden , and assisting physicians to furnish patient health information concerning my relevant medical history (including but not limited to the super confidential information listed above) to any of the following: Other healthcare providers involved in my care, insurance carriers, attorneys and adjustors.

4 I hereby assign to Steven V Nguyen, , David A. Padden , and assisting physicians all payments for Medical Services rendered to myself or my dependents. I understand that I am responsible for any amount not covered by insurance. Signature: Patient Parent/GuardianDate/Time: PATIENT RELEASEI, _____, hereby authorize Optimotion Orthopaedic and its physicians to release any or all of my patient health information including super confidential information to the person(s) listed below. (Example: A Spouse or relative may be involved in billing and insurance inquires or medication refills.) Signature: Date/Time: Name: Relationship to PatientPhone: PRIVACY NOTICE Inspect and Copy Your Protected Health Information (PHI): You have the right to inspect and copy your protected health information that may be used to make decisions about your care, with the exception of psychotherapy notes.

5 If you want to see or copy your medical information, you must submit your request in writing to the Privacy Site Coordinator or to the Optimotion Orthopaedic Privacy Officer. If you request copies of information, the cost will be $ per page for the first 25 pages then .25 per page after. In accordance with Health Information Portability and Accountability Act (HIPPA), patients of Optimotion Orthopaedics are entitled to and afforded the rights to privacy regarding their health related information as set forth under applicable law. Optimotion Orthopaedics will strive to ensure that patient information is used only for purposes authorized by the patient and as otherwise required by law.

6 Upon request we can provide you with a complete copy of our Privacy Policies. Additionally, Patients have a right to review their medical records and furnish comments to their records during normal business hours, upon providing reasonable advance notice. CANCELLATION POLICY If unable to keep your appointment, kindly give 24 hour notice to avoid $ no show charge. Copays, deductibles, and coinsurance will be collected prior to treatment. If payment is not received at the time services are rendered the patient will receive 3 statements in regards to an outstanding balance. If your account is still delinquent, your account will be sent to collections. Signature: _____ Date/Time: _____ Optimotion ORTHOPAEDICS Steve Nguyen, MD, PA.

7 / David Padden, 5979 Vineland Rd. Suite 101 Orlando, FL 32819 Phone: (407) 355 3120 Fax: (407) 355 3119 Knee intake form of prior treatment Date: _____ Please answer the following questions and sign the bottom of this page. Which knee(s) do you want to see the doctor for today? Left Right How long have you had this pain _____ Pain Level? 0 10 _____ Which of the following prior treatments have you tried prior to discussing knee replacement? Please check all that apply: Anti inflammatory medications (Aspirin, Ibuprofen, Naproxen, Indomethacin, Meloxicam, etc.) Duration? _____ Physical Therapy When? _____ Activity modification (reduced physical activity such as sports, exercise, stairs, or walking) Assistive devices (cane, walker, etc.)

8 Cane Walker Crutches Wheelchair Other: Knee braces Injections Cortisone HYALGAN SYNVISC Other: Weight loss Prior knee surgery; please specify: Have you ever consulted any other physician regarding your knee? Yes No What is the name/phone of this doctor? _____ What was the determination and recommended treatment given by this physician? _____ _____ Have you ever undergone knee replacement surgery? Yes No If yes which knee _____ o If so, who was the performing doctor & phone? _____ o Name of component/prosthesis if known? _____ Patient Name: _____ DOB: _____ Signature: _____ Dear Sir/Madame, In order for our office to facilitate the scheduling of your surgery, we require you to make a surgery deposit and to follow our office surgery cancellation and postponing policies.

9 Surgery deposit: Our office requires a $ surgery deposit. ONLY DEBIT/CREDIT CARDS ARE ACCEPTED FOR SURGERY DEPOSITS We will waive this requirement if you are an established patient and are scheduling a 2nd surgery. Upon receiving this $ deposit, the front desk will give you two things: 1. The PowerPoint presentation: You will listen to and watch this PowerPoint while in the office. When you finish the PowerPoint presentation, you will meet with our surgery coordinator to schedule a surgery date and address all your concerns 2. The surgery packet : The surgery packet has every step on what needs to be done in regards to your surgery. It is very important that you read the entire packet at home and keep it as your guideline.

10 Surgery cancellation and postponing policies: Your surgery deposit will not be refunded back to you if you cancel surgery within 30 days for a non medical reason. Our office needs to receive a notice more than 30 days prior to surgery of your cancellation by certified mail or email at If you want to be eligible to move your surgery date up, please inform our surgery coordinator to put your name on the cancellation list. When there is an earlier surgery date available you will be called to move up. Dr. Nguyen Dr. Padden Patient Signature: _____ Date: _____ 5979 Vineland Rd. Suite 101 Orlando, FL 32819 Phone: 407 355 3120 / Fax: 407 355 3119 FALL RISK ASSESSMENT Patient Name:_____ DOB : _____ 1.