New Patient Intake Form - ELITE Sports Medicine - Orthopedic Surgeon Palm Beach, Sports Medicine West Palm Beach

New Patient Consultation Intake Form

Patient Demographics

First Name *

Last Name *

Date of Birth *

Sex *

Male Female

Phone Number *

Email Address

Address

City

State

Zip Code

Marital Status

Single Married Divorced Widow

Spouse's Name

Spouse Phone Number

Emergency Contact

Emergency Phone

Relationship to Patient

Patient Medical History

Allergies

Other Allergies

Family History

Please indicate if any immediate relatives have had the following conditions.

Condition	Mother	Father
Anesthesia Problems
Arthritis
Cancer
Diabetes
Heart Problems
Hypertension
Stroke
Thyroid Disorder

Social History

Surgical History

Please list any hospitalizations, surgeries, fractures or major illnesses you have had.

Type of Surgery	Year/Date	Doctor	Location

Medical History

Have you ever had any of the following?

If Diabetes, last A1C

Medications

List any medications you are currently taking (please include over-the-counter medications). Please print legibly — no cursive.

Medication	Dosage

Prescription Policy

Pharmacy Name

Pharmacy Address

Pharmacy Phone

Please acknowledge the following policies:

Do not wait until your last pill to call for a refill. 72-hour turnaround required.
If you have not seen the physician in six months, your refill may be denied.

I have read and understand the prescription policy outlined above.

HIPAA Compliance – Patient Consent Form

The Health Insurance Portability and Accountability Act (HIPAA) provides patients with fundamental rights to privacy regarding their protected health information (PHI). Elite Sports Medicine is committed to protecting your medical information and complying with HIPAA regulations.

Consent to Use and Disclose Health Information

By signing this form, I consent to the use and disclosure of my protected health information by Elite Sports Medicine for the purposes of treatment, payment, and healthcare operations. This may include coordination and management of healthcare, communication with other providers, billing and payment, and routine healthcare operations.

Right to Revoke

I understand that I have the right to revoke this consent in writing at any time, except to the extent that Elite Sports Medicine has already taken action based on my prior consent.

Notice of Privacy Practices

I acknowledge that I have received and had an opportunity to review a copy of Elite Sports Medicine's Notice of Privacy Practices.

I have read and agree to the HIPAA Consent and Privacy Practices above.

Authorization for Communication

Individuals we may share your health information with:

Name

Relationship

Name

Relationship

May we leave a message regarding your care on your voicemail?

Yes No

Signature

Patient/Guardian Signature *

Printed Name *

Relationship to Patient (if applicable)

Date *

HIPAA Notice of Privacy Practices

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

1. Uses and Disclosures of Health Information

We may use and disclose your health information for treatment, payment, and healthcare operations. For example, we may share information with other healthcare providers involved in your care, or with your insurance company to obtain payment for services.

2. Your Rights

You have the right to: request restrictions on certain uses and disclosures of your information, receive confidential communications, inspect and copy your medical record, request an amendment to your record, receive an accounting of disclosures, and obtain a paper copy of this notice.

3. Our Legal Duties

We are required by law to maintain the privacy of your health information, provide you with this notice of our legal duties and privacy practices, and abide by the terms of this notice.

4. Complaints

If you believe your privacy rights have been violated, you may file a complaint with our office or with the Secretary of the U.S. Department of Health and Human Services.

To file a complaint with our office, contact: Privacy Officer, Elite Sports Medicine, Phone: (561) 202-8886.

To file a complaint with the Secretary of HHS, contact: U.S. Department of Health and Human Services – Office for Civil Rights, 200 Independence Avenue, S.W., Washington, D.C. 20201, Phone: 1-877-696-6775, Website: hhs.gov/ocr.

Effective Date: June 4, 2025

Medical Services Agreement

1. Medical Consent

I hereby consent to medical evaluation and treatment by the providers and staff at Elite Sports Medicine. This may include diagnostic procedures, medical treatments, and other services deemed necessary for my care. I understand that I have the right to be informed about my treatment options and to ask questions regarding my care.

2. Financial Agreement

I understand and agree that all charges for services rendered by Elite Sports Medicine are due at the time of service unless other arrangements have been made in advance. This includes, but is not limited to, copayments, deductibles, and coinsurance amounts as required by my health insurance policy.

3. Insurance and Patient Responsibility

I understand that it is my responsibility to know and understand the terms of my health insurance coverage. While Elite Sports Medicine may assist in verifying insurance benefits, it is ultimately my responsibility to ensure that services are covered. I acknowledge that my insurance provider may not cover all services in full, and I agree to pay any remaining balance not covered by my insurance.

4. NO-SHOW Fee Agreement

If I fail to show up for a scheduled appointment without providing at least 24 hours' notice, I will be charged a $35.00 no-show fee. This fee is not covered by insurance and must be paid prior to scheduling any future appointments.

5. Late Arrival Policy

There is a 15-minute grace period for scheduled appointments. If I arrive more than 15 minutes past my appointment time, my appointment may be rescheduled at the discretion of the provider. Repeated late arrivals may also be subject to the no-show policy.

I acknowledge that I have read, understood, and agree to the Medical Services Agreement.

By signing below, I acknowledge that I have read, understood, and agree to the terms outlined above.

Patient/Guardian Signature *

Relationship to Patient (if applicable)

Printed Name *

Date *

Consent to Treatment

I voluntarily consent to receive medical care, treatment, and services by the providers and staff at Elite Sports Medicine, including but not limited to physical examinations, diagnostic tests (e.g., X-rays, lab work), medical treatments, procedures, or therapies, and administration of medications.

I understand that I have the right to ask questions and be informed about the benefits, risks, and alternatives to any recommended treatment. I understand that I may refuse any treatment and that such refusal will not jeopardize my future care.

I certify that I have read, understood, and agree to the above consent statements, and I authorize the medical staff of Elite Sports Medicine to provide evaluation and treatment as deemed necessary.

Signature & Submission

By signing below, you confirm that all information provided is accurate and complete to the best of your knowledge. You acknowledge that you have read, understood, and agree to all policies and consents outlined in this intake form.

Printed Name *

Date *

Signature *

Relationship to Patient (if applicable)

Witness Name

Thank You!

Your intake form has been submitted successfully. Our office will contact you shortly.

Patient Demographics

Insurance Information

Secondary Insurance

Patient Medical History

Allergies

Family History

Social History

Surgical History

Medical History

Medications

Prescription Policy

HIPAA Compliance – Patient Consent Form

Consent to Use and Disclose Health Information

Right to Revoke

Notice of Privacy Practices

Authorization for Communication

Signature

HIPAA Notice of Privacy Practices

1. Uses and Disclosures of Health Information

2. Your Rights

3. Our Legal Duties

4. Complaints

Medical Services Agreement

1. Medical Consent

2. Financial Agreement

3. Insurance and Patient Responsibility

4. NO-SHOW Fee Agreement

5. Late Arrival Policy

Consent to Treatment

Signature & Submission

Thank You!