New Patient Forms


 

To save time at check in, please click on your providers name below. Print and fill out all new patient forms attached and bring them with you to your appointment. 

To complete your registration we will need to scan your insurance card AND a photo ID. Please bring these items with you to your appointment.

If your insurance plan requires a physician referral to see a specialist, please make the appropriate arrangements with your primary care physician BEFORE your appointment at Western Orthopaedics, PC. Without this permission (a referral) we are unauthorized to see you. 

If you are being treated due to an auto or work related injury, you will be asked to provide the following information-Name of insurance company, claim address, claim number, adjusters name and phone number. Please be advised that authorization is required PRIOR to your office visit or we are unable to treat you.

 


Click Below to Access Forms

 

Sean Baran, MD

New Patient Medical Profile

Financial Agreement

Authorization for the use or disclosure of protected health information

Mobility

If you need assistance from your vehicle to our suite, please bring someone to assist you. Unfortunately, we do not have extra staff members available to assist everyone with mobility needs.

Translation

If you require a translator for your appointment, please bring someone to translate for you. If you are unable to bring a translator, please contact our office 1 week prior to your appointment so we may make the appropriate arrangements.

 
Rajesh Bazaz, MD

Financial Agreement

Health History

Mobility

If you need assistance from your vehicle to our suite, please bring someone to assist you. Unfortunately, we do not have extra staff members available to assist everyone with mobility needs.

Translation

If you require a translator for your appointment, please bring someone to translate for you. If you are unable to bring a translator, please contact our office 1 week prior to your appointment so we may make the appropriate arrangements.

 
Timothy Birney, MD

Financial Agreement

Health History

Mobility

If you need assistance from your vehicle to our suite, please bring someone to assist you. Unfortunately, we do not have extra staff members available to assist everyone with mobility needs.

Translation

If you require a translator for your appointment, please bring someone to translate for you. If you are unable to bring a translator, please contact our office 1 week prior to your appointment so we may make the appropriate arrangements.

 
Armodios Hatzidakis, MD

Financial Agreement

Health History

SPOT-Subjective Outcome Patient Tracker

Authorization for Continuity of Care

HIPAA Release

Mobility

If you need assistance from your vehicle to our suite, please bring someone to assist you. Unfortunately, we do not have extra staff members available to assist everyone with mobility needs.

Translation

If you require a translator for your appointment, please bring someone to translate for you. If you are unable to bring a translator, please contact our office 1 week prior to your appointment so we may make the appropriate arrangements.

 
James Holmes, MD

Financial Agreement

Health History

Mobility

If you need assistance from your vehicle to our suite, please bring someone to assist you. Unfortunately, we do not have extra staff members available to assist everyone with mobility needs.

Translation

If you require a translator for your appointment, please bring someone to translate for you. If you are unable to bring a translator, please contact our office 1 week prior to your appointment so we may make the appropriate arrangements.

 
Thomas Mordick, MD

Financial Agreement

Health History

Mobility

If you need assistance from your vehicle to our suite, please bring someone to assist you. Unfortunately, we do not have extra staff members available to assist everyone with mobility needs.

Translation

If you require a translator for your appointment, please bring someone to translate for you. If you are unable to bring a translator, please contact our office 1 week prior to your appointment so we may make the appropriate arrangements.

 
Kevin Nagamani, MD

Financial Agreement

Health History

Mobility

If you need assistance from your vehicle to our suite, please bring someone to assist you. Unfortunately, we do not have extra staff members available to assist everyone with mobility needs.

Translation

If you require a translator for your appointment, please bring someone to translate for you. If you are unable to bring a translator, please contact our office 1 week prior to your appointment so we may make the appropriate arrangements.

 
Edward (Ted) Parks, MD

Financial Agreement

Health History

Mobility

If you need assistance from your vehicle to our suite, please bring someone to assist you. Unfortunately, we do not have extra staff members available to assist everyone with mobility needs.

Translation

If you require a translator for your appointment, please bring someone to translate for you. If you are unable to bring a translator, please contact our office 1 week prior to your appointment so we may make the appropriate arrangements.

 
Benjamin Sears, MD

Financial Agreement

Health History

Elbow Questionnaire

Shoulder Questionnaire

Mobility

If you need assistance from your vehicle to our suite, please bring someone to assist you. Unfortunately, we do not have extra staff members available to assist everyone with mobility needs.

Translation

If you require a translator for your appointment, please bring someone to translate for you. If you are unable to bring a translator, please contact our office 1 week prior to your appointment so we may make the appropriate arrangements.

 
Steven Traina, MD

Financial Agreement

New Patient Health History

Mobility

If you need assistance from your vehicle to our suite, please bring someone to assist you. Unfortunately, we do not have extra staff members available to assist everyone with mobility needs.

Translation

If you require a translator for your appointment, please bring someone to translate for you. If you are unable to bring a translator, please contact our office 1 week prior to your appointment so we may make the appropriate arrangements.

 
Brian White, MD

Financial Agreement

Initial Patient Evaluation

Health History

Mobility

If you need assistance from your vehicle to our suite, please bring someone to assist you. Unfortunately, we do not have extra staff members available to assist everyone with mobility needs.

Translation

If you require a translator for your appointment, please bring someone to translate for you. If you are unable to bring a translator, please contact our office 1 week prior to your appointment so we may make the appropriate arrangements.

 
Rose Christensen MSPAS, PA-C

Financial Agreement

Health History

SPOT-Subjective Outcome Patient Tracker

Authorization for Continuity of Care

HIPAA Release

Bone Health Intake Form

Mobility

If you need assistance from your vehicle to our suite, please bring someone to assist you. Unfortunately, we do not have extra staff members available to assist everyone with mobility needs.

Translation

If you require a translator for your appointment, please bring someone to translate for you. If you are unable to bring a translator, please contact our office 1 week prior to your appointment so we may make the appropriate arrangements.

 
Andrew Cleveland PA-C, MSPAS, MPH

Financial Agreement

New Patient Health History

Mobility

If you need assistance from your vehicle to our suite, please bring someone to assist you. Unfortunately, we do not have extra staff members available to assist everyone with mobility needs.

Translation

If you require a translator for your appointment, please bring someone to translate for you. If you are unable to bring a translator, please contact our office 1 week prior to your appointment so we may make the appropriate arrangements.

 
Shawn Karns MPA, PA-C

Financial Agreement

Initial Patient Evaluation

Health History

Mobility

If you need assistance from your vehicle to our suite, please bring someone to assist you. Unfortunately, we do not have extra staff members available to assist everyone with mobility needs.

Translation

If you require a translator for your appointment, please bring someone to translate for you. If you are unable to bring a translator, please contact our office 1 week prior to your appointment so we may make the appropriate arrangements.

 
Dina Richter MMS, PA-C

Financial Agreement

Health History

SPOT-Subjective Outcome Patient Tracker

Authorization for Continuity of Care

HIPAA Release

Mobility

If you need assistance from your vehicle to our suite, please bring someone to assist you. Unfortunately, we do not have extra staff members available to assist everyone with mobility needs.

Translation

If you require a translator for your appointment, please bring someone to translate for you. If you are unable to bring a translator, please contact our office 1 week prior to your appointment so we may make the appropriate arrangements.

 
Greg Turner PA-C

Financial Agreement

Health History

Mobility

If you need assistance from your vehicle to our suite, please bring someone to assist you. Unfortunately, we do not have extra staff members available to assist everyone with mobility needs.

Translation

If you require a translator for your appointment, please bring someone to translate for you. If you are unable to bring a translator, please contact our office 1 week prior to your appointment so we may make the appropriate arrangements.