Central States Orthopedic Specialists 
 6585 South Yale, Suite 200 
 Tulsa, OK 74136 
 

PATIENT	LAST		FIRST		MIDDLE	AGE	MALE
							FEMALE

MAILING ADDRESS	HOME PHONE

CITY		STATE	ZIP	EMPLOYER		OCCUPATION

EMPLOYER'S ADDRESS		CITY		STATE	ZIP	WORK PHONE

PATIENT SOCIAL SECURITY			DATE OF BIRTH			MEDICARE #

MARITAL STATUS				SPOUSE'S NAME

GUARANTOR	SOCIAL SECURITY NO.	RELATIONSHIP	BIRTHDATE

ADDRESS		CITY		STATE	ZIP	HOME PHONE

EMPLOYER	ADDRESS	WORK PHONE

PRIMARY INSURANCE CO.	ADDRESS

POLICY HOLDER NAME	BIRTHDATE	SOCIAL SECURITY #	GROUP #

POLICY HOLDER EMPLOYER	ADDRESS

SECONDARY INSURANCE CO.	ADDRESS

POLICY HOLDER NAME	BIRTHDATE	SOCIAL SECURITY #	GROUP #

POLICY HOLDER EMPLOYER	ADDRESS

NEAREST RELATIVE (not at same address)
ADDRESS	HOME PHONE

FAMILY DOCTOR	PHONE

CHIEF COMPLAINT OR AREA OF BODY INVOLVED	RIGHT	LEFT

DATE OF ACCIDENT OR ONSET OF SYMPTOMS				If Accident, where did it happen?	HOW?
TIME	MONTH	DAY	YEAR	Auto    Other
DATE WORK WAS STOPPED (If Applicable)				Describe accident and/or symptoms.
TIME	MONTH	DAY	YEAR
DATE RETURNED TO WORK (If Applicable)
TIME	MONTH	DAY	YEAR

PREVIOUS TREATMENT FOR THIS INJURY?	BY WHOM?	WHERE?	WHEN?
YES    NO

HOW?

ALLERGIES?	TO WHAT?
YES    NO

ARE YOU PRESENTLY UNDER TREATMENT FOR ANY OTHER ILLNESS OR INJURY? (Please Explain)

ARE YOU PREGNANT OR IS THERE ANY CHANCE YOU COULD BE?   YES    NO

CHIEF COMPLAINT OR AREA OF BODY INVOLVED	RIGHT	LEFT

HOW DID YOU FIND OUT ABOUT CENTRAL STATES ORTHOPEDIC SPECIALISTS, INC.?

To my knowledge the above information is correct. I give my consent for treatment for this illness or injury described herein and I understand that I am financially responsible to Central States Orthopedic Specialists, Inc. for all charges not covered by any and all insurances. If payment is not made at the time services are rendered, adequate provision must be made for payment and additional credit information may be required. I understand that both parents of a minor patient may be asked to sign a statement of financial responsibility and that if a patient is married, under some circumstances, the patient's spouse will be required to sign the statement of financial responsibility. I authorize payment directly to Central States Orthopedic Specialists, Inc. of any insurance policy benefits payable to me, and I hereby assign all such policy benefits to Central States Orthopedic Specialists, Inc.
PATIENT'S SIGNATURE	DATE

SIGNATURE OF ADDITIONAL RESPONSIBLE PARTY	RELATIONSHIP	DATE
Central States Orthopedic Specialists, Inc. A Professional Corporation reserves the exclusive right to designate which of its employees shall perform service.