Plaza Orthopedic & Sports - Wellness 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your patient information, including the date, referring physician, and personal details such as name and date of birth. Ensure accuracy for effective communication.
3. Indicate your gender and marital status. Fill in your mailing address and contact numbers to facilitate easy correspondence.
4. If applicable, provide information about the responsible party, including their relationship to you and their contact details.
5. Complete the insurance coverage section by listing your primary and secondary insurance providers along with subscriber details.
6. Review the authorization section carefully. Sign and print your name to authorize payment and release of medical information.
7. Fill out the past medical history, chief complaints, social history, drug allergies, and medication list sections by circling or writing relevant information.
8. Lastly, complete any additional authorizations required for medical records release or advanced directives as needed.

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