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New Patient Form

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New Patient Form

This form is also available as a printable PDF: New Patient Form (Print)

Great River Spine Clinic LogoWelcome to Great River Spine. To expedite your chart preparation, please have the form below filled out completely & submitted successfully (you will be taken to a confirmation page upon submission). The receptionist will need to have a copy of your driver’s license and insurance card at the time of your visit.

Please note the following:

  • X-rays/MRI’s/CT scans etc. :
    1. Please bring your X-Rays, MRIs, and/or CAT Scans with you to your appointment. Having the studies put on a CD Rom is acceptable.
    2. If these studies have been done at Great River Medical Center we will   arrange to have them here for you.
  • Insurance: Bring your insurance card with you so that our receptionist can make a copy.  You are responsible for your co-pay or percentage (10-20 %…) that your insurance will not pay, at the time of your visit.
  • Worker’s Compensation: You will need to supply us with your employer information, date of accident, WC insurance company name, address of where to mail claims, and a claim number.
  • Motor Vehicle Accident: We apologize, but our doctor does not file on auto insurance.
  • Medicaid: Before seeing a specialist, Medicaid requires that you obtain a Medicaid referral from your PCP (primary care physician).  If this is not obtained, Medicaid will not pay your specialist, and you will be responsible for the bill; therefore, if you have not obtained a referral, we require you to pay for your visit in full at the time of service.
  • No Insurance: You will be responsible for full payment of your visit at the time of service.
  • Medications: No medications are dispensed out of this office without Dr. Foster’s approval. Please allow 24-48 hours for medication refill requests, as Dr. Foster is in surgery 2 days per week and needs adequate time to approve requests.
  • Cancellations: Please be considerate and notify our office 24 hours prior to your appointment if you need to cancel or reschedule, as there may be other patients needing that appointment time.
  • If you are unable to comply with any of the above, please call our office prior to your visit to discuss these requirements.

Patient Information

* Please fill out this entire form. Thank you. *

Who referred you?

Where is your problem now? Select your symptom(s) in their location(s).

Describe your pain.
How long have you had this problem?

Explain How Your Pain or Problem Began

Yes / No
On the job injury?
Legal action is pending?
Is your injury related to a motor vehicle accident?
I don't know how it began
How bad is your pain now? Please describe your pain on a scale from 0 to 10. 0 equals no pain and 10 equals the worst possible pain.

Past Medical History / Illness

Heart trouble:
Liver Disease:
Kidney Disease:
Lung Disease:
Blood Disorder:
Eye Disorder:
Psychological Difficulties:

Surgeries / Injuries

Year: Year:

Spine Surgery / Year

Year: Procedure / Level:

Childhood Diseases

Family Medical History

Members of my family (Mother, Father, Brothers, or Sisters) have the following medical conditions:

Social History

I drink

Use of tobacco products?

If using currently, have you ever tried to quit?

Have you been exposed to second hand smoke?
My recreational activities include:

Review of Systems

Do you have problems with:
Yes / No **Please add comments if you answer yes to any of the following:

Job History

In my job, I do the following:

Please List All of the Medications You Are Currently Taking:

Pescription Medication: Dosage: (mg. & # per day) Reason: (Blood Pressure, Etc…)
Non-Pescription or As Needed Medications: (Tylenol, Ibuprofen, Vitamins, Etc…)
Medication: Dosage: (mg. & # per day) Reason: (Blood Pressure, Etc…)

Please List Any Allergies: (Drugs, Food, Etc…)

Allergy To: Raction: (Itching, Hives, Etc…)

Okay, does everything look correct?