Resurgens Joint Replacement Center

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Second Surgical Opinion

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Patient Information

First Middle Initial Last Address City State Zip Gender Date of Birth (mm/dd/yyyy) Social Security # (last 4 digits) Primary Care Physician Referring Physician (if different) Employer Employer Phone Daytime Phone Evening Phone Cell Phone Emergency Contact name Problem/Accident/Illness Accident/Illness Date Marital Status Email Address

Guarantor Information

Guarantor Same as Patient Yes Guarantor First Name Middle Initial Last Name Guarantor Street Address City State Zip Guarantor Daytime Phone Guarantor Evening Phone Guarantor Date of Birth (mm/dd/yyyy) Guarantor Social Security # (last 4 digits) Guarantor Employer Guarantor Employer Phone

Next of Kin

Next of Kin Relationship Evening Phone

Policy Holder Information

Policy Holder Same as Patient Yes Policy Holder First Name Middle Initial Last Policy Holder Street Address City State Zip Policy Holder Gender Policy Holder Date of Birth (mm/dd/yyyy) Policy Holder Daytime Phone

Insurance Information

Employer Phone Name of Insurance Group Number Insurance Phone Policy Number Type of Plan If other, please list Effective Date

Appointment Information

Physician Preference Preferred Time of Day Preferred Date of Appointment Insurance Company If Other, specify: Reason for Visit If Other, specify: Is this visit work-related? Yes No Is this visit auto-related? Yes No

I understand that Resurgens Orthopaedics cannot guarantee privacy for e-mail communications over the internet, other than website submissions from their official website, www.resurgens.com. I understand and accept this risk, and thus, will allow Resurgens Orthopaedics to communicate my protected health information using my personal e-mail address listed above.

Please be advised that our office will contact your insurance company to verify coverage and we will also contact you prior to your visit to confirm date, time, and location of your appointment.

Resurgens Orthopaedics

Greater Atlanta's Premier Joint Center

Resurgens Spine Center

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Second Surgical Opinion