1. Healthcare

Jackson Orthopaedic Clinic
Patient Information (Please Print)
Name___________________________________________________ Date of Birth ____________________ Sex: F or M
Mailing Address____________________________________________________________________________________
City____________________________________State__________________________________Zip_________________
Home Phone _________________________________________ Cell Phone ___________________________________
E-mail Address _______________________________________ Work Phone __________________________________
Marital Status
Ethnicity:
M D S W
SSN _____________________________ Race _______________________________
Hispanic or Latino Not Hispanic or Latino  Choose not to answer  Other
Name of Employer__________________________________________________________________________________
Primary Care Physician: _____________________________________________________________________________
Which doctor referred you to Dr. Gandy? ________________________________________________________________
Responsible Party Information (if patient is responsible party, skip this section)
Name ___________________________________________________________________________________________
Mailing Address ___________________________________________________________________________________
City____________________________________State__________________________________Zip_________________
Date of Birth ______________________________________________ SSN ___________________________________
Relationship to Patient ______________________________________________________________________________
Insurance Information
Primary Insurance______________________________________________ ID # ________________________________
Insured’s Name __________________________________________Date of Birth _______________________________
Relationship to Patient ______________________________________________________________________________
Mailing Address____________________________________________________________________________________
City____________________________________State__________________________________Zip_________________
Secondary Insurance _______________________________________________ ID # ___________________________
Insured’s Name __________________________________________Date of Birth _______________________________
Relationship to Patient ______________________________________________________________________________
Mailing Address____________________________________________________________________________________
City____________________________________State__________________________________Zip_________________
Authorized Persons
Please list any person authorized to speak with us on your behalf.
_________________________________________________________________________________________________
Name
Phone Number
Relation to patient
_________________________________________________________________________________________________
Name
Phone Number
Relation to patient
_________________________________________________________________________________________________
Name
Phone Number
Relation to patient
Preferred Pharmacy Information
Pharmacy Name ___________________________________________ City ____________________________________
Name of Street ____________________________________________Phone Number ___________________________
Do you authorize Jackson Orthopaedic Clinic to receive your prescription history electronically?____Yes ______ No
University of Mississippi Medical Center Family Medicine Resident Program
Dr. Gandy has residents (medical doctor in training) from the University Of Mississippi Medical Center accompany him on
monthly rotations. This resident will observe and assist Dr. Gandy at the time of your visit.
Do you agree to allow the resident in your exam room during your visit?
_____ Yes ______ No
________________________________________________________________________________________________
Signature
Date
Acknowledgement of Receipt of Notice of Privacy Practices
Notice to Patient:
We are required to provide you with a copy of our Notice of Privacy Practices, which states how we may use and/or
disclose your health information. Please sign this form to acknowledge receipt of the Notice. You may refuse to sign this
acknowledgement, if you wish.
I acknowledge that I have received a copy of this office’s Notice of Privacy Practices.
_________________________________________________________________________________________________
Please print your name here
_________________________________________________________________________________________________
Signature
For Office Use Only
We have made every effort to obtain written acknowledgement of receipt of our Notice of Privacy from this patient but it
could not be obtained because:
The patient refused to sign.
Due to an emergency situation, it was not possible to obtain an acknowledgement.
We weren’t able to communicate with the patient.
Other (provide specific details)
________________________________________________________________ ______________________________
Employee Signature
Date
Jackson Orthopaedic Clinic
Consent for Treatment
Authorization for treatment and release of medical information
Authorization to Release: I hereby authorize Jackson Orthopaedic Clinic and Dr. David Gandy to provide treatment to
me, to release or disclose to insurance companies and/or outpatient benefit programs and their designees all
information from my medical record pertaining to my medical treatment as needed to process insurance claims.
Authorization to release: Work or school excuse to my employer /school official should the need arise.
Consent for Treatment: The undersign patient or patient’s representative authorize(s) Dr. David Gandy at Jackson
Orthopaedic Clinic to furnish medical and surgical treatment by those means he considers necessary and proper in the
treatment of the patient identified below while a patient of Jackson Orthopaedic Clinic. This treatment may require
diagnostic procedures including but not limited to x-rays, aspirations, injections, application of cast or splint, or
reduction of a displaced fracture.
Consent for retirement of x-ray films and graphic data: The undersigned authorizes the clinic to retire x-ray films and
any other graphic data, which may be generated, seven years after they are generated if the written and signed findings
of a radiologist or other professional who has interpreted the x-ray or graphic data is maintained in the medical record.
Valuables: The undersigned hereby releases Jackson Orthopaedic Clinic and its staff or employees from any
responsibility due to loss or damage of any valuables that the patient may keep in his/her possession or that may be
brought to him/her by other persons while on the premises of Jackson Orthopaedic Clinic.
_____________________________________________
Patient Name
_____________________________________________
Signature
________________________________________________
Date
Jackson Orthopaedic Clinic
Financial Policy
We participate in several healthcare networks, as well as Medicare. It is your responsibility to inform us if your
insurance program is affiliated with a network and to let us know if a referral or preauthorization is required. Your must
provide an insurance/Medicare card so we can determine benefits, and we must know when there are any changes in
your coverage. All portions of any deductible or co-pays are due at the time of service. If the physician you are seeing
is not a member of your network, you will be responsible for any portion your insurance does not pay.
Secondary Insurance Policies: We will be happy to file your secondary insurance. However, if we have not received a
response from them within 45 days, the balance will be transferred to the patient.
Please remember that your insurance policy is a contract between you and your insurance company. We will see that
your claim(s) are filed properly, but is your responsibility to follow- up and see that claim(s) are paid in a timely
manner. Should problems arise with your insurance company, we will gladly assist you in determining what steps need
to be taken. You are always responsible for your account, regardless of insurance coverage.
We make every effort to work with our patients regarding their accounts and we encourage you to keep us informed of
any special circumstances. However, it is sometimes necessary to rely on an outside agency to assist us in collections.
Should it become necessary for your account to be assigned to an agency, a 35% collection fee will be added to the
account when it is turned over for collections.
I understand that I am financially responsible for all charges incurred at Jackson Orthopaedic Clinic, and that I am
responsible for any surgical charges that are incurred with Jackson Orthopaedic Clinic. I also understand that I am
responsible for all statements, collection fees and/or attorney fees that may be added to my account due to my failure
to pay my account in full and/or in a timely manner.
I have read the financial policy of Jackson Orthopaedic Clinic and agree to the above conditions.
___________________________________________________
Signature of Responsible Party
___________________________________________________
Patient’s Name
_________________________
Date
Jackson Orthopaedic Clinic
Current Medical History
Name: _____________________________________________________________ Today’s Date: __________________
PLEASE USE THE BACK OF THIS PAPER IF NEEDED.
IF A PARTICULAR CATEGORY DOES NOT APPLY, PLEASE WRITE N/A.
Medications- Please list your current medications.
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Medical History- Please circle.
High Blood Pressure
Rheumatoid Arthritis
Sleep Apnea
Heart Disease/ Problems
Sickle Cell
Kidney Disease
Liver Disease
Seizures
Poor Healing
Asthma
Lung Disease
Stroke
HIV/ AIDS
Osteoporosis
Diabetes
Cancer_________(type)
Other:__________________________________________________________________________________________
Allergies-Please list your medication allergies and type of reaction.
Medication
_____Reaction ______
Medication
_____Reaction ______
_____________________________________________
_____________________________________________
______________________________________
______________________________________
_____________________________________________
_____________________________________________
Surgical History-Please list previous surgeries and the date of the surgery.
_Surgery________________________Date__________
__Surgery___________________________Date______
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Hospitalizations- Please list previous hospitalizations include date and why you were hospitalized.
Reason
_______
Date ______
Reason
_______
Date ______
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Family History
Diseases/ Health Problems
Father __________________________________________
Mother __________________________________________
Brother __________________________________________
Sister __________________________________________
Diseases/ Health Problems
Grandfather (mom’s side)____________________________
Grandmother (mom’s side)___________________________
Grandfather (dad’s side)_____________________________
Grandmother (dad’s side)___________________________
Name_____________________________________________________________________
Yes
No Weight Change
Yes
No Pregnant
Yes
No Fatigue
Yes
No Difficulty urinating
Yes
No Headache
Yes
No Painful urination
Yes
No Night Sweats
Yes
No Cold extremities
Yes
No Eye symptoms
Yes
No Decreased sensation in extremities
Yes
No Vision Problems
Yes
No Pain/cramping in legs after exertion
Yes
No Ear, Nose, or Throat Problems
Yes
No Painful extremities
Yes
No Excessive sweating
Yes
No Hives
Yes
No Excessive thirst
Yes
No Keloid formation
Yes
No Sleep Apnea
Yes
No Rash
Yes
No Wheezing
Yes
No Skin lesions
Yes
No Chest pain at rest
Yes
No Balance difficulty
Yes
No Chest pain with exertion
Yes
No Dizziness
Yes
No Difficulty breathing with exertion
Yes
No Gait abnormality
Yes
No Irregular heartbeat
Yes
No Loss of strength
Yes
No Shortness of breath
Yes
No Loss of use of extremity
Yes
No Abdominal pain
Yes
No Seizures
Yes
No Change in bowel habits
Yes
No Tingling/Numbness
Yes
No Diarrhea
Yes
No Anxiety
Yes
No Nausea
Yes
No Depressed Mood
Yes
No Vomiting
Yes
No Difficulty sleeping
Yes
No Easy bruising
Yes
No Substance abuse
Yes
No Prolonged bleeding