New Patient Registration

Let's get your paperwork out of the way.

This covers everything for your first visit: contact info, symptoms, accident details if applicable, medical history, and required consents. It takes about 10–15 minutes.

1. Patient Registration

Basic information so we can set up your chart and reach you about your visit.

I consent to receive appointment reminders via: *
Best time to reach you: *

2. Symptoms & Pain Assessment

List everything that applies — this helps us prepare before you arrive.

Symptoms (check all that apply) *
Body parts injured (check all that apply) *
Pain is worsened by: *

3. Accident / Injury Details

Complete this section if your visit relates to an auto accident, work injury, or slip and fall.

Type of accident

Auto Insurance / PIP Information

4. Medical History

Please check any condition that applies and add comments where relevant.

ConditionYesNoComments
Past surgeries
Diagnostic imaging you've had
Metals or plastics in your body

5. Assignment of Benefits, Consent & Financial Responsibility

This covers all dates of service related to this accident. Only one signature is required per accident.

By signing below, I acknowledge and agree to the following:

• Assignment of Benefits: I assign all insurance benefits, settlements, and proceeds to Forge Spine & Injury PLLC for services related to this accident.

• Direction to Pay: I direct all insurers, attorneys, and responsible parties to pay Forge Spine & Injury PLLC directly.

• Authorization: I authorize Forge Spine & Injury PLLC to negotiate claims on my behalf; request IMEs, EOBs, denial letters, and payment logs; endorse checks in my name; and communicate with my attorney regarding billing and settlement.

• Financial Responsibility: I am personally responsible for all charges regardless of insurance coverage, claim denials, or case outcome. Attorney representation does not transfer this responsibility.

• Settlement: Payment is not contingent upon settlement or verdict. I agree to pay any balance not covered by insurance or settlement proceeds.

• Medical Lien: Forge Spine & Injury PLLC may place a medical lien on any settlement, judgment, or verdict obtained in connection with my accident claim to recover the balance of charges for services rendered.

• Consent for Treatment: I consent to physical examinations, diagnostic tests (including X-rays, nerve studies), and treatment procedures as medically necessary. I understand there are no guarantees of improvement.

• Medical Records: I authorize release/receipt of medical records, X-rays, and payment information to/from providers, insurers, employers, and legal representatives involved in my care.

• A photocopy or electronic copy of this form is valid as the original.

6. PIP Standard Disclosure and Acknowledgment

Personal Injury Protection — initial treatment or service provided.

The undersigned insured person (or guardian of such person) affirms:

1. The services or treatment set forth were actually rendered — meaning those services have already been provided.

2. I have the right and the duty to confirm that the services have already been provided.

3. I was not solicited by any person to seek any services from the medical provider described above.

4. The medical provider has explained the services to me for which payment is being claimed.

5. If I notify the insurer in writing of a billing error, I may be entitled to a portion of any reduction in the amounts paid by my motor vehicle insurer — at least 20% of the reduction, up to $500, if entitled.

7. HIPAA Authorization

Authorization to use and disclose protected health information.

I authorize Forge Spine & Injury PLLC to use and disclose my health information for:

• Treatment — sharing with other healthcare providers

• Payment — submitting claims to insurers, attorneys, third-party payers

• Healthcare Operations — quality improvement and administrative functions

• Legal Proceedings — providing records to my attorney and parties in my injury claim

Your rights: This authorization is voluntary. You may refuse to sign, revoke it at any time in writing (revocation will not affect prior disclosures), request copies of your records (fees may apply), and request amendments. Information disclosed to non-healthcare entities may no longer be protected by federal law.

I authorize Forge Spine & Injury PLLC to discuss my medical information with (optional):

By typing your name above and submitting, you are signing this form electronically. Your information is sent securely to our office. If you have questions before submitting, call us at 786-947-6068.