The following forms are provided for your convenience and ease in preparing for your visit to Midwest Orthopaedic Institute. Please contact us with any questions or concerns in filling out any forms. Thank You.
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Patient History Sheet-both sides
This will assist your physician in making a diagnosis, assessing, and treating your present problem. This form also requests a list of your current medications, the dose, and how long you have taken each one.
Rheumatology Patient History Form
If your appointment is scheduled with one of our Rheumatologists click on physicians name to download and use one of these forms.
Laura M. Lemke, M.D., F.A.A.O.S. Patient Forms
If your appointment is scheduled with Laura M. Lemke, M.D., F.A.A.O.S. click on the links below to download and use this form(s).
Jacinthe V. Malalis, D.O. Patient Forms
If your appointment is scheduled with Jacinthe V. Malalis, D.O. click on the links below to download and use one of these forms.
Patient Registration Form
This form defines your consent to treat, release of information, financial responsibility and authorization to discuss your account. Medicare patients use this form to assign Medicare and Medi-Gap benefits.
Rehabilitation Therapy Patient Forms
If you have been referred to one of our Rehabilitation Therapy centers, please complete this multi-page form and bring it to your first visit.
HIPPA NOTICE OF PRIVACY PRACTICES
This notice will tell you about the ways we may use and share medical information about you. It will also describe your rights and certain duties we have regarding the use and disclosure of medical information.
Payment Policy-both sides
This explains our policies and procedures involved with payment for services rendered at our facility.