- Foot Surgery
- Fracture Care
- General Orthopaedics
- Hand Surgery
- Joint Replacement
- Pediatric Orthopaedics
- Physical Medicine
- Spine Care
- Sports Medicine
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OUR PHYSICIANS:
- Kirk D. Clifford, MD
- Mary Beth Deering, MD
- Michael P. Dohm, MD
- Michael Dolecki, MD
- David P. Fisher, MD
- Robert L. Frazho, MD
- James S. Gebhard, MD
- Steven J. Heil, MD
- Michael J. Huang, MD
- Waqqar Khan-Farooqi, MD
- Mark G. Luker, MD
- Jeffrey M. Nakano, MD
- Richard J. Price, MD
- Michael T. Reeder, DO
- Michael D. Rooks, MD
- James K. Weaver, MD
- Thea A. Wojtkowski, MD
FOR PATIENTS: Patient Intake Forms
Most of the forms you might be asked to complete can be found on this page.
In order to better serve you, there are several items of information we will need before you are seen by the doctor. A lot of the information will be used by the physician to help evaluate your condition as well as to identify the best course of treatment. It is very important that you provide accurate information regarding your medical history, medications and allergies.
We will also collect information that will allow us to bill your insurance. If you were injured in an accident we will need information to determine the proper party to bill.
All patient information is safeguarded in accordance with federal HIPAA (Health Information Portability and Accountability Act) guidelines.
Please click here to download and view a copy of our privacy policy.
If you are not sure which forms you need to complete, please call our office and one of our schedulers will assist you.
Please download and complete the applicable forms, below.
If you are a new patient or have not been seen in the last year, please complete the following forms:
These forms are required.Patient Intake Form
Patient Demographic and Insurance Information
If you were injured in an accident, please complete this form:
Accidental Injury FormIf you are being seen due to back pain or injury, please complete one of the following forms:
If you are seeing Dr. Dohm Back Pain QuestionnaireIf you are seeing Dr. Clifford, Frazho or Gebhard Patient History for Back Disorders
If you are seeing Dr. Clifford, Frazho or Gebhard Patient History for Neck Disorders