PROGRESS: Page 1 of 12

DEV New Patient Information
Thank you for pre registering online for your upcoming appointment at Lincoln Orthopaedic Center. Please allow 15 minutes to complete the process in its entirety. Please have your medications and insurance information available. You will not be able to save your work and go back at a later time to finish. If you have difficulty when registering please call 402-436-2000.
We understand that the privacy and security of your personal information is important. Lincoln Orthopaedic Center, P.C. adheres to confidentiality standards that are designed to protect your personal information. We provide a safe, reliable and secure Website that has several levels of security. We do not sell our customer lists and/or the personal information contained therein. We only use your personal information to help us provide your care. This Web site does not collect personally identifying information about you except when you specifically and knowingly provide it. Under certain circumstances, Lincoln Orthopaedic Center, P.C. may be required or permitted by law to disclose your personal information.

Items marked with an * are required.
Salutation
Name*
First NameMiddle NameLast Name
Suffix
Invalid Input

Address*
Invalid Input
City*
Invalid Input
State*
Invalid Input
Zip*
Invalid Input

Date of Birth* / /
Sex*
Required
Marital Status*
Required
Student Status*
Required
Home Phone*
Invalid Input		 Please enter your 10 digit number.
Cell Phone
Invalid Input		 Please enter your 10 digit number.
Email Address*
Invalid email.		 If you do not have an email address, put in none
 
Having problems completing the form? We're here to help! 402-436-2000 or E-Mail Us
Employment Information
Employers Name*
Invalid Input		 Enter "none" if you are not employed.
Employers Address
If you are employed, you must include your employers address. If not employed, enter "none" in the Employers Name box.
Occupation*
If you are employed, you must include your occupation. If not employed, enter "none" in the Employers Name box.
Employers Phone*
Invalid Input
Employers Phone Ext
Invalid Input
 
Having problems completing the form? We're here to help! 402-436-2000 or E-Mail Us
Spouse's First Name*
Invalid Input
Spouse's Middle Name
Invalid Input
Spouse's Last Name*
Invalid Input
Spouse's Employer
Invalid Input
Employer's Address
Invalid Input
Phone
Invalid Input
 
Having problems completing the form? We're here to help! 402-436-2000 or E-Mail Us
Emergency Contact: This is a person NOT living with you.
Emergency contact first name*
Invalid Input
Middle Name
Invalid Input
Last Name*
Invalid Input
Relationship*
Invalid Input
Home Phone*
Invalid Input
Work Phone
Invalid Input
Ext
Invalid Input
 
Having problems completing the form? We're here to help! 402-436-2000 or E-Mail Us
Other Information
Who Referred You?*
Invalid Input
Family Doctor Please enter "none" if you do not have a family doctor.
Invalid Input
Do you have Medical Insurance Coverage?*
You must indicate if you have insurance.
Primary Medical Insurance Information
Primary Insurance Carrier*
If you indicated you are using Primary Medical Insurance on the previous page, this field is required.
Insurance Carrier Phone
Invalid Input
ID #*
If you listed a Primary Insurance Carrier, this field is required.
Policy Holder's Date of Birth* mm/dd/yyyy
If you listed a Primary Insurance Carrier, this field is required, and must be mm/dd/yyyy
Group or account #
Invalid Input
Policy Holders First Name*
If you listed a Primary Insurance Carrier, this field is required.
Policy Holders Middle Name
Invalid Input
Policy Holders Last Name*
If you listed a Primary Insurance Carrier, this field is required.
Relationship to Policy Holder*
Policy Holder's Employer*
If you listed a Primary Insurance Carrier, this field is required.
* Secondary Medical Insurance Information
Secondary Insurance Carrier*
If you indicated you are using Primary Medical Insurance on the previous page, this field is required.
Insurance Carrier Phone
Invalid Input
ID #*
If you listed a Primary Insurance Carrier, this field is required.
Policy Holder's Date of Birth* mm/dd/yyyyIf you listed a Primary Insurance Carrier, this field is required, and must be mm/dd/yyyy
Group or account #
Invalid Input
Policy Holders First Name*
If you listed a Primary Insurance Carrier, this field is required.
Policy Holders Middle Name
Invalid Input
Policy Holders Last Name*
If you listed a Primary Insurance Carrier, this field is required.
Relationship to Policy Holder*
 
Having problems completing the form? We're here to help! 402-436-2000 or E-Mail Us
Responsible Party (If patient is a minor or dependent adult)
Salutation
Invalid Input
First Name*
Please type your full name.
Middle Name
Invalid Input
Last Name*
Suffix
Invalid Input
Address*
Invalid Input
City*
Invalid Input
State*
Invalid Input
Zip*
Invalid Input
Home Phone*
Invalid Input		 Please enter your 10 digit number
Employers Name
Invalid Input		 Enter "none" if you are not employed.
Employers Address
Invalid Input
Employers Phone
Invalid Input
Employers Phone Ext
Invalid Input
Parental Authorization Form - pdf If the patient is not accompanied by his/her legal guardian LOC must have the Parental Authorization form signed by a legal guardian and witness. **IMPORTANT: Minor must bring the completed Parental Authorization Form to the appointment. If LOC does not have authorization we may reschedule the appointment.
 
Having problems completing the form? We're here to help! 402-436-2000 or E-Mail Us
Authorization
Patient or Authorized Name*
Invalid Input		 Typing name constitutes signature
 
Having problems completing the form? We're here to help! 402-436-2000 or E-Mail Us

Personal Health History

We require the completion of this form for your visit. If this form is not completed online, you will be asked to complete it when you arrive.
Patient Name*
Invalid Input
Height* feet / inches
Invalid Input
Weight* Pounds
Invalid Input
 
Having problems completing the form? We're here to help! 402-436-2000 or E-Mail Us
List any surgeries/fractures or other major illnesses or injuries.
Type Year
Hospital Surgeon
Type Year
Hospital Surgeon
Type Year
Hospital Surgeon
Type Year
Hospital Surgeon
 
Having problems completing the form? We're here to help! 402-436-2000 or E-Mail Us
Do you have or have you had:


















Invalid Input
Please explain any items you checked above or list any information you feel would be important to your treatment
Invalid Input
Do you smoke?*
Invalid Input
If Yes how many packs per day
If you answered yes to smoking, this field is required.
Recreational drug use*
Invalid Input
If yes, type:*
If you answered yes to any recreational drug use, this field is required.
Alcohol Use*
Invalid Input
Do you have a special diet?*
Invalid Input
Type
Invalid Input
List ALL medications you are now taking, including herbals and over-the-counter. Enter "none" if you are not taking any medications*
Invalid Input
What pharmacy do you normally use? (Pharmacy name and location):
Example: CVS- 66th & O, Walgreens*
Invalid Input
Do you take aspirin daily:*
Invalid Input
If yes, type:
Invalid Input
Do you take a blood thinning medication (i.e. Coumadin)*
Invalid Input
If yes, type:
Invalid Input
Do you have any known allergies (drugs, food, etc.)*
Invalid Input
If yes, allergy and reaction Please input each as ALLERGY - Reaction, one per line
Invalid Input
Do you have an allergy to LATEX?*
Invalid Input
If yes, reaction
Invalid Input
 
Having problems completing the form? We're here to help! 402-436-2000 or E-Mail Us

Health History Continued
Have you or anyone in your family (Mother, Father, Sister, Brother, Child) ever had a reaction to any anesthetic, general or local, causing high fever, blood pressure problems, or any other type of allergic reaction? *
Invalid Input
If yes, please explain
If you answered yes to any relative having had a reaction, this field is required.
Has anyone in your immediate family had the following? If so, please tell us who. (i.e. Mother, Father, Brother, Sister, Child, etc). You must choose at least one option.
Invalid Input
Relationship*
Invalid Input
Relationship*
Invalid Input
Relationship*
Invalid Input
Relationship*
Invalid Input
Relationship*

What are we seeing you for today? (for example: left foot, right knee)*
Invalid Input
Date of injury or when you first noticed symptoms* mm/dd/yyyy
Must be mm/dd/yyyy
List any symptoms (Ex. Pain, Swelling, Numbness)*
Invalid Input
Is the problem you will be seen for due to an injury?*
Invalid Input
If yes, was there an accident?*


Invalid Input
Where did the injury occur? (Home, work, etc: location or address)*
If you answered yes to problem being due to an injury, this field is required.
How did the injury occur?*
Invalid Input
Has this injury been reported to your employer?*
Invalid Input
Supervisor*
Invalid Input
Workers Compensation Carrier
Invalid Input
Work Comp Claims Address & Phone
Invalid Input
Work Comp Claim Number Invalid Input If Unknown, please provide at appointment
Was this an auto accident?*
Invalid Input
Have you reported this to an insurance company?*
Invalid Input
to whom?*
Invalid Input
Insurance Carrier for the Property Where Accident Occurred*
Invalid Input
Claim Filing Address
Invalid Input
Claim Adjuster Name and Phone Number*
Invalid Input
Claim Number
Invalid Input
What were you doing at the time?*
Invalid Input
Patient's Auto Insurance Carrier*
Invalid Input
Other Vehicle Auto Insurance Carrier
Invalid Input
Other Vehicle Claim Filing Address
Invalid Input
Other Vehicle Claim Adjuster Name and Phone Number
Invalid Input
Other Vehicle Claim Number
Invalid Input
Other Driver/Insured's Name
Invalid Input
Was an accident report filed?*
Invalid Input
Where?*
Invalid Input
Please bring a copy of the report if the accident occurred outside Lincoln, NE
Were you*
Invalid Input
If Other*
Invalid Input
Have you retained an attorney regarding this accident?*
Invalid Input
Attorney name,phone, & address*
Invalid Input
Did you have emergency room treatment?*
Invalid Input
If so, where
Invalid Input
In the past two years, regarding the body part we are seeing you for, have you had:
X-Ray*
Invalid Input
If so, where?
Invalid Input
MRI?*
Invalid Input
If so, where?
Invalid Input
CT?*
Invalid Input
If so, where?
Invalid Input
Physical therapy?*
Invalid Input
If so, where?
Invalid Input
Cortisone?*
Invalid Input
If so, by whom?
Invalid Input
 
Having problems completing the form? We're here to help! 402-436-2000 or E-Mail Us
* I have read and agree to the financial policy and I hereby authorize the release of any medical information necessary to process my health insurance and request payment of benefits to the provider of services. I understand I am financially responsible to Lincoln Orthopaedic Center for charges not covered or denied by my insurance carrier. I further agree that in the event of my non-payment, to pay the cost of collection and / or court costs and reasonable fees should this be required.
This is required.
Patient or Authorized Name* Typing name constitutes signature
Typing name constitutes signature