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Registration Form

If you will not be able to complete this form in one sitting, please create an account where you can log in and save your progress. Once logged in, you can save your form progress by clicking the “Save Draft” button located at the bottom of the form next to the submit button. (The “Save Draft” button will only display if you’re logged in.)

PLEASE NOTE – to save progress, you need to CREATE AN ACCOUNT FIRST. If you do not, your progress and DATA WILL BE LOST.

Registration Form
If patient is a minor (under the age of 18), please check box and complete additional questions.
Any patient under the age of 18 must be accompanied by a parent or appointed guardian for ALL appointments.

Father's Information

Mother's Information

In The Event The Parent/Guardian Is Not Present

How did you hear about us? *
Extremity Affected *
Hand Dominance *
Location of Symptoms?
What type of injury or condition is this? *

Third Party Liability Information

Please contact the responsible party for accurate billing information BEFORE your appointment with our specialist to avoid receiving a billing statement. Please note: The belief that a third party is responsible for your condition does not guarantee payment. For this reason, we require all patients provide private health insurance information (if applicable), including insurance card(s) at the initial visit. This will expedite processing your claims in the event of a third party denial. Also, if your health insurance is an HMO or requires an authorization to be seen by a specialist, we strongly suggest contacting your primary care physician to obtain a referral prior to your appointment for the best benefits available to you in case your third party liability claim is denied or exhausted.
Type of Third Party Liability Accident *
What insurance coverage should we bill first? *
Claims mailing address or PO Box *
Claims mailing address or PO Box
City
State/Province
Zip/Postal

Worker's Compensation Information

Please contact your employer for accurate billing information BEFORE your appointment with our specialist to avoid receiving a billing statement. Please note: The belief that your injury is work related does not guarantee payment by your employer’s work compensation insurance carrier. For this reason, we require all patients provide private health insurance information (if applicable), including insurance card(s) at the initial visit. This will expedite processing your claims in the event of a worker’s compensation denial. Also, if your health insurance is an HMO or requires an authorization to be seen by a specialist, we strongly suggest contacting your primary care physician to obtain a referral prior to your appointment for the best benefits available to you in case your worker’s compensation claim is denied.
If Worker’s Compensation, have you filed a FIRST REPORT of injury with your employer? *
Address *
Address
City
State/Province
Zip/Postal
Claims mailing address or PO Box *
Claims mailing address or PO Box
City
State/Province
Zip/Postal
How did the pain that you are currently experiencing occur? *
Are you having numbness and pain? *
Please move the blue box and select your current level of pain (zero being no pain, 10 being most severe)
What treatment have you had for this? *
Has this been associated with any other problems elsewhere on your body? *
Are you involved in any legal action regarding your physical complaint?
Are you presently receiving psychiatric treatment?
Have you been told of difficulty with placement of a breathing tube during anesthesia? *
Do you have problems with anesthesia? *
Do you have a history of a tracheotomy? *
Are you pregnant? *
Are you breast feeding? *
Do you have a personal or family history of Malignant Hyperthermia? *

Previous or Present Health Conditions (Section 1)

Previous or Present Health Conditions (Please check if applicable)

Previous or Present Health Conditions (Section 2)

Previous or Present Health Conditions (2nd Row)
Are you allergic to any medications? *
Are you allergic to latex *
Are you allergic to food/environment/other *
Have you ever tested positive for MRSA? *

Family History

Reviewed Family Section

Review of System

Physician and Pharmacy Information

Terms and Conditions *

Directions to Appleton Clinic (2323 N. Casaloma Drive)
Directions to Green Bay Satellite Office (1551 Park Place, Suite 100)