Thank you for scheduling an appointment with one of our physicians. It is our pleasure to welcome you to the
Department of Orthopaedic Surgery and Sports Medicine in advance of your first visit.
Downtown:
The Orthopaedic Clinic is located at Two Medical Park, Lower Level, Suite L9/ L10.
The Sports Medicine Clinic is located at Two Medical Park, Suite 104.
Parkridge:
The Parkridge Clinic is located at 300 Parkridge Drive, Suite 201, Columbia, SC 29212
Below are important items you need to look over prior to your first visit to our practice. Some require action on
your part.
Insurance Coverage: Please bring your insurance card to your scheduled appointment. Without verification
of your insurance coverage your appointment may be rescheduled, or you will be expected to pay all fees at the
time services are rendered.
If your insurance carrier requires referral authorizations, it is your responsibility to check with your primary
care physician to ensure they have authorized your visits to our office. Without this authorization you will be
expected to pay for the services you receive, on the date of your appointment, in full.
Medical Information: Please have your medical records forwarded to us prior to your appointment. We need
to review these records which may include x-rays, MRI’s, bone scans, and notes of visits to other physicians.
Please bring with you all medications you are currently taking so we can accurately document this information
in your patient chart.
Medical History Forms: Attached you will find medical history forms that will need to be completed prior to
your visit at our office. These forms, completed in entirety, are required in our office prior to being seen by any
of our physicians. You may either bring the completed forms with you on the day of your appointment or mail
them if time allows.
Minors under the Age of 18: Patients that are under the age of 18 must be accompanied by a parent/legal
guardian. If a parent/legal guardian is unavailable to attend the visit, the form Consent to Medical Treatment
and Responsibility for Medical Charges for Minors must be filled out and given at time of check in.
Cancellation Policy: Patients will be accessed a $25 fee for all appointments not cancelled 24 hours in
advance.
No Show Policy: Patients that miss over 3 scheduled appointments in one calendar year will not be allowed to
schedule another appointment.
Any of the above information that is missing on the day of your scheduled appointment may cause a reschedule
of your appointment. We encourage you to arrive 30 minutes prior to your scheduled appointment time. If you
have any questions prior to your visit, please contact our office by calling 803-434-6812.
kjh 5-26-15
DEPARTMENT OF ORTHOPAEDIC SURGERY
803-434-6812, FAX 803-434-7306
www.uscortho.com/www.uscsportsmedicine.com
Please Print Clearly – Thank You!
DATE
PATIENT INFORMATION
First Name
Middle Initial
Last Name
Street Address
City
State
Zip
Mailing Address
City
State
Zip
Email Address
Employer/School_
Occupation
Employer Address
City
Home Phone #
Date of Birth
State
Work Phone #
Zip
Cell Phone #
Social Security #_
Driver’s License #
Nearest relative not living with you:
Phone #
Primary Care Physician:
Referred to this office by:
Preferred Pharmacy (name and address):
PRIMARY INSURANCE
Policy #_
Group #
Insured’s Name
Relationship to Patient
Insured’s Social Security # or ID #
Insured’s DOB
Insurance Co. Name
Insurance Co. Phone #
Insurance Co. Address
City
State
Zip
SECONDARY INSURANCE
Policy #_
Group #
Insured’s Name
Relationship to Patient
Insured’s Social Security # or ID #
Insured’s DOB
Insurance Co. Name
Insurance Co. Address
Insurance Co. Phone #
City
State
Zip
DEPARTMENT OF ORTHOPAEDIC SURGERY
803-434-6812, FAX 803-434-7306
www.uscortho.com/www.uscsportsmedicine.com
revised 5.26.15
Name:_
MRN:
DOB:
/
/
Visit Information
Reason for visit:
Referring Physician:
Date of Injury:
Primary Care Physician:
Type of Pain:
Stabbing
Ache
Severity: None 0 1 2 3 4 5 6 7 8 9 10
(10=Worst Pain)
Previous Tests:
X-ray
CT
Pain Aggravated By:
Standing
Sleeping
Sitting
Walking
Working
Driving
Lying
Stairs
Throbbing
Shooting
Duration of Pain:
/
Dull
Site of Pain (mark on images)
Front
Back
/
Click/Pop
R
MRI Location of Test:
Treatments Attempted:
Anti-inflammatory
Pain Medications
Injection
Physical Therapy
Surgery
Splint/Boot/Brace
L
L
R
Rest
Ice
NONE
Please Explain your current problem, in detail. Include location of problem, symptoms, how long you have experienced those
symptoms, and the severity of them. Include what makes problem worse or better.
Current Health
Seizures
Liver Disease/Jaundice
Osteo Arthritis/Gout
Chronic Headache
Infections: Please Explain:
Other Illness: Please Explain:
Please list any health problems that you are currently diagnosed with:
Lung Disease
High Blood Pressure Thyroid Problems
Stomach Ulcers
Heart Disease
Cancer
Kidney Disease
Asthma
Diabetes
HIV/AIDS
Depression
High Cholesterol
Pulmonary Embolism
DVT (Blood Clots)
Rheumatoid Arthritis
Hepatitis C
Height:
Weight:
Surgical History
Please list any previous surgeries and approximate dates of surgery:
Surgery:
Known Allergies to Anesthesia:
No
Date:
/
/
/
/
/
/
/
/
Yes
Surgery:
Describe:
NONE
Date:
/
/
/
/
/
/
/
/
Medications
Please list any medications that you currently use, including over-the-counter medications, vitamins, herbs, and prescribed drugs.
Medication:
Dose:
Medication:
Department of Orthopaedic Surgery
NONE
Dose:
Please Turn Over
Allergies
Known Drug Allergies:
NONE
Latex
Penicillin
Acetaminophen
Sulfa Drugs
Other:
Morphine
Ibuprofen
Diagnostic Dyes
Aspirin
Iodine
Codeine
Family History
Problem:
Diabetes:
Heart Disease:
Asthma:
Other:
Does it run in your family?
No
No
No
No
Please list family member (s) who have had this health issue.
Yes
Yes
Yes
Yes
No
No
No
Arthritis:
Blood Clots:
Cancer:
Yes
Yes
Yes
Social History
Occupation:
Current:
Past :
Do you live alone:
Do you smoke?
Do you drink alcohol?
Any substance abuse?
Disabled
Retired
Yes
Yes
Yes
Yes
No
No
No
No
With whom?
How many packs per day?
Type:
Frequency
Please List:
Reason for Disability:
Daily
Quit?
Weekly
Months ago
Monthly
Yearly
Years ago
Review of Systems:
Yes/No
Check yes if applicable.
Yes/No
Weight Loss
Chills
Fever
Decreased Appetite
Blurred Vision
Glasses
Contacts
Vision Loss
Hearing Loss
Sore
Dentures
Heart Attack
Aortic Aneurysm
Palpitations
Leg Swelling
Heart Murmur
Shortness of Breath
Sleep Apnea
Wheezing
Pneumonia
Productive Coughing
Bladder Infections
Blood in Urine
Burning When Voiding
Other:
MD Only: All other systems reviewed and found to be negative
Yes/No
Yes/No
Incontinence
Hemorrhoids
Kidney Stones
Injury
Joint pain
Muscle Pain
Swelling
Easy Bruising
Rash
Dizziness
Tingling
Fainting
Bad Balance/Falling
Stroke
Trouble with Memory
Edema
Anemia
Bleeding Disorders
Blood Clots
Sexually Transmitted Disease
Anxiety
Sleep Disturbances
Numbness
Headaches
Signature
Signatures
Patient Signature:
Date:
Department of Orthopaedic Surgery
/
/
Authorization Regarding Payment and Release of Medical Information
Patient’s Name:
Chart #:
I hereby authorize and request the payment of services from Medicare, Medicaid and/or other insurance plans or payors be
made on my behalf to University Specialty Clinics – Department of Orthopaedics. I hereby assign to University Specialty
Clinics – Department of Orthopaedics all payments for treatment services. I hereby allow University Specialty Clinics to file
an appeal for me with Medicare, Medicaid and/or other insurance plans or payors for any reason. I understand and agree that
I am responsible for paying any amount not covered by Medicare, Medicaid and/or other insurance plans or payers.
(PLEASE READ THE ATTACHED FINANCIAL AND INSURANCE POLICY FOR OUR PRACTICE)
I hereby authorize the release of medical information to Medicare, Medicaid and/or insurance plans or other payers. I also
authorize the release of medical information to other healthcare providers including, but not limited to, my primary care or
family physician, consulting physicians or healthcare providers, hospitals, rehabilitation center, or other healthcare providers
or facilities. I authorize my healthcare providers to review my prescription history from my pharmacist(s) for purposes of
treatment. I permit a copy of this authorization to be used.
Patient’s/Patient’s representative’s Signature
Witness Signature
Date
Date
Printed patient’s or Representative’s Name
Representative’s relationship to Patient
Consent to Treatment
I hereby agree to and give consent to the physicians, healthcare providers, associates, and consultants of University Specialty
Clinics – Department of Orthopaedics , and residents of affiliated institution, Palmetto Health, to diagnose and treat me. I
consent to any and all treatment including, but not limited to, physical examinations, psychological examinations, x-rays,
laboratory procedures, and other procedures related to routine diagnosis and treatment as determined appropriate by the
practice’s physicians, healthcare providers, associates, consultants and residents.
I give permission to share my electronic medical record among my healthcare providers and obtain medication history
through a Provider Health Information Exchange (HIE). The University Specialty Clinics will abide by state and federal law
regarding the availability to and access by the other medical providers of any sensitive information, such as behavioral health,
substance abuse treatment, sexual abuse, genetic test results, HIV/AIDS status and adoption records. I MAY OPT OUT OF
THE HIE BY COMPLETING THE OPT- OUT FORM AND CONTINUE TO RECEIVE CARE.
Patient’s/Patient’s representative’s Signature
Witness Signature
Date
Date
Printed patient’s or Representative’s Name
Representative’s relationship to Patient
Authorization to Release Information to Coach or Athletic Trainer
I authorize the release of medical information to the coach or athletic trainer of the school/athletic organization listed below
for the purpose of providing the best comprehensive care. I may revoke this authorization at any time. Such revocation must
be in writing and delivered to University Specialty Clinics. The revocation will not apply to records and information that
have already been disclosed.
School/Athletic Club
Rev 3-4-15
If under age 18, Parent or Legal Guardian’s
Department of Orthopaedic Surgery
Two Medical Park, Suite 404, Columbia, SC
803-434-6812
Signature Date
University Specialty Clinics Notice of Privacy Practices
By signing below, I state that I have been given my own copy of the University Specialty Clinics’
Notice of Privacy Practices, effective date August 1, 2013.
Printed Name of Patient
Signature of Patient
Date
OR
Printed Name of Patient’s Representative
Signature of Patient’s Representative’s
Date
Description of Authority to Act on Behalf of Patient
Effective Date
11/27/2013
Department of Orthopaedic Surgery
Two Medical Park, Suite 404, Columbia, SC
803-434-6812