Patient Intake Form Please complete the form below. Click submit when ready! Please enable JavaScript in your browser to complete this form.Name *FirstLastCheckboxesMaleFemaleDate of Birth (xx/xx/xxxx)FL AddressCityStateZip CodeOut of State AddressCall PhoneHome PhoneEmail AddressClosest Relative NamePhoneDrivers License NumberPrimary InsuranceID #Secondary InsuranceID #Is this a Work Comp CaseYesNoWork Comp Claim #Date of Injury (xx/xx/xxxx)AdjusterPhoneEmployer*Are you Currently Staying at Any Rehab/Nursing/Facility?YesNoHeightWeightName of Doctor who Referred you HereItem OrderedHave you Worn/Received this Item or One Similar (for the same body part) Before?YesNoNot SureIf You Answered Yes to the Previous Question, When?Was it for the same injury?YesNoWhere did You Get the Brace?What Happened to the Brace?I give Orthocare Permission to contact me by phone, mail, or email regarding the services they provide. I understand that custom orders ordered by my doctor and made by Orthocare cannot be returned and therefore authorize Orthocare to bill my Insurance even if I refuse the item at delivery. I agree to pay any amounts not paid by my Insurance company.ConfirmPatient Name (or Responsible Party) *FirstLastTyping your First and Last Name acts as your electronic signature acknowledging and confirming the above statement Date (xx/xx/xxxx)If you signed on behalf of the patient, please state your relationship to the patient.Submit Our Services Prosthetics Orthotics Ancillary Equipment Pediatrics Prosthetic Delivery Service
