Orthopedic Specialists of North Texas

Forms

Insurance

Forms
There are three forms needed for your visit. First, review the Privacy Statement and check the box that you have reviewed it. We apologize for this step, but it is required by the U.S. Government. Open each form, type in the answers on the computer, and then print out each form. Take care of these forms and bring them to your appointment. If you do not bring these forms to your first visit, you will have to fill them out in the office before you can be seen by the doctor.

Privacy Notice

Patient Forms

Patient Information Form

Accident Details Questionnaire

H&P (Dr. Michael House Only)

H&P (All other doctors)

Patient Financial Policy Form

Release of Medical Records Form

Disability/FMLA/Insurance Form

MRI Forms

MRI – What to Expect

MRI Patient Medical Questionnaire

BRING TO YOUR APPOINTMENT

Completed/Signed Above Forms
Insurance Card(s)
X-Rays on disk or film and the X-Ray report
MRI or CT on disk or film and the MRI or CT report
MRI Patient Medical Questionnaire
Any other forms the office has requested you bring to appointment

The PDF forms on this site require Adobe’s Acrobat Reader. If you do not have Acrobat Reader installed on your system, please visit the Adobe website at http://www.adobe.com.