Registration Form

Columbus Orthopaedic Clinic, P.A.

In order to avoid a delay, this form must be completed in its entirety.

Today's Date *
Physician * Rhea
Linton
Jones
Altmyer
Weeks
PATIENT INFORMATION
Last Name *
First *
Middle *
Prefix Mr.
Mrs.
Miss.
Ms.
Marital Status * Single
Mar
Div
Sep
Is this your Legal Name * Yes
No
If not, what is your legal name?
Birth date *
Age *
Sex * M
F
Street address *
Social Security # *
Home Phone # *
P.O. Box:
City *
State *
Zip *
Occupation *
Employer
Employer's Address
Employer's Phone
Spouse/Father's Name
Spouse/Father's Employer
Spouse/Father's Employer's Address
Spouse/Father's Employer's Phone
Spouse/Father's SSN#
Mother's Name
Mother's Birth Date
Mother's DOB
Mother's Address (if different)
Mother's Home phone
Mother's SSN#
Mother's Employer
Mother's Employer Address
Mother's Employer Phone
INSURANCE INFORMATION
Is this patient covered by Insurance? Medicare
Blue Cross
Workman's Comp
Car Insurance
Tricare
Please indicate primary Insurance School Insurance
No Insurance
Other
Medicaid
Insurance Address
Subscriber's SSN#
Subscriber's Birth Date
Group #
Policy #
Co-Pay Amount
Patient's relationship to subscriber self
spouse
child
other
Name of secondary Insurance (if applicable)
Secondary Insurance Address
Secondary Group #
Secondary Policy #
Secondary Subcriber's Name
Secondary Subscriber's SSN#
Secondary Subscriber's DOB
Patient's relationship to Secondary Subscriber
Name of local friend or relative (not living at same address):
Emergency Contact's relationship to patient
Emergency Contact's home phone
Emergency Contact's work phone
Patient/Guardian Name *
Date *
SSN# *
I agree *