Rocky Mountain Orthopaedic Associates
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 forms are in Adobe Acrobat format. You will need Adobe Reader 5.0 or later to view and print these forms - it is free by clicking here.

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.

These forms are required.	If you are a new patient or have not been seen in the last year, please complete the following forms:	Patient Intake Form Patient Demographic and Insurance Information
--- AND --- you may need one of these.	If you were injured in an accident, please complete one of the following forms:	All Rocky Mountain HMO or PPO plan members Rocky Mountain Health Plans Injury Form All other patients Accidental Injury Form
--- AND --- you may need one of these.	If 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 Questionnaire If you are seeing Dr. Clifford, Frazho or Gebhard Patient History for Back and Neck Disorders
--- AND --- you may need one of these.	If you are scheduled for Bone Density testing, please complete the following:	Bone Densitometry Patient Questionnaire

Rocky Mountain Orthopaedic Associates 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
Sandra A. Horvath-Dori, 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