Hand to ShoulderOnline Reg Form

Appointment Date

Last Name of Patient (include Jr., II, III, etc., if applicable) *

First Name of Patient *

M.I.

Date of Birth *

*

Yes, Patient is a Minor

No, Patient is NOT A Minor

Social Security # (last 4 digits) *

Name of School Patient is Attending *

Any patient under the age of 18 must be accompanied by a parent or appointed guardian for ALL appointments.

Sex: *

Male

Female

Other

Gender Identity:

Preferred Pronoun(s):

Height *

Weight *

Home Phone (Home or Cell Required)

Cell Phone

Work Phone

Preferred method for appointment reminders: *

Text

Voice Message

Can the office communicate via text? *

Yes

No

By checking this box, I consent to receive conversational/scheduling SMS from Hand to Shoulder Center of Wisconsin. Reply STOP to opt-out; Reply HELP for support; Message & data rates may apply; Messaging frequency may vary. Visit https://handtoshoulderwisconsin.com/privacy-policy/ to see our privacy policy and https://handtoshoulderwisconsin.com/sms-texting-policy/ Terms of Service

Can the office email you unencrypted? *

Yes

No

Email

Address

City

State/Province

Zip/Postal

Occupation *

Employer Name

Marital Status *

Spouse’s Name

Spouse’s Date of Birth

Spouse’s Social Security # (last 4 digits)

Spouse’s Place of Employment

Personal Insurance Carrier’s Name

Subscriber/Member ID #

Group #

Policy Holder Name/Relationship to Patient

Parent/Guardian #1

Parent/Guardian #2

In The Event The Parent/Guardian Is Not Present

Referral, Provider, and Pharmacy Information

What is your preferred local pharmacy for short term scripts? (Name/Street/City)

How did you hear about us? *

Who referred you?

Primary Care Provider

Clinic Name

For statistical purposes only as required by the State of Wisconsin

Race *

Ethnicity *

Hispanic or Latino

Not Hispanic or Latino

Refused to Report

Preferred Language *

English

Spanish

OtherOther

Check if you would prefer appointment reminders via text/voice in Spanish

Yes, send my reminders in Spanish

Emergency Contacts

Patient Authorization for use and disclosure of Protected Health Information (PHI) from the practice. Our office may contact you or any emergency contacts with appointment, billing, and protected health information (PHI) through home, cell, or work numbers provided. It is your responsibility to inform the company of any changes.

Name/Relationship (required)

Phone #

Name/Relationship

Phone #

Name/Relationship

Phone #

Name/Relationship

Phone #

Notice of Privacy Practices

It is important that you provide accurate and complete information during registration for your safety. As you read the privacy policy link provided, it will detail for you the following: 1. We will use the information you provide for your treatment. 2. We will use your information to receive payment for services. 3. We may use your diagnosis, treatment, and outcome information to improve the quality or cost of care. These quality and cost improvement activities may include evaluating the performance of your doctors, nurses and other health care professionals, or examining the effectiveness of the treatment provided to you when compared to patients in similar situations. 4. We may use your information to assist us in communicating with you about appointment reminders, test results, and treatment information. Our communications to you may be by phone, text, email, patient portal, and mail. If you are unavailable, our health professionals will use their best judgement in communicating with your contacts.

I acknowledge that a copy of the Notice of Privacy Practices have been made available to me from Hand to Shoulder Center of Wisconsin and Woodland Surgery Center. Privacy Policy located in the link.

Yes

Click here to read the Privacy Policy

Patient/Representative Signature for Privacy Policy/HIPAA/Emergency Contacts

First name Digital Signature

Last name Digital Signature

Date

If personal representative signed, describe relationship.

As part of the 21st Century Cures Act, the practice is enrolled in Carequality/Commonwell health information exchange. Upon query, authorized staff has access to necessary electronic health information. If you wish to opt out, please check the box and your records cannot be queried.

OPT OUT