ATLANTA UNITED ORTHOPAEDIC & SPORTS MEDICINE
Patient Demographic and Insurance Form
Last Name_____________________________________First Name_______________________________________MI ___________
Address_________________________________________City________________________, State__________, ZIP______________
E-mail ______________________________________________________________________________________________________
Home Phone_________________________________________Work Phone______________________________________________
Cell Phone___________________________________________Fax_____________________________________________________
Date of Birth_____________________ Sex_________ Social Security Number____________________________________________
Emergency Contact___________________________________________Relationship_______________________________________
Home Number________________________________________Cell Number_____________________________________________
Guarantor___________________________________________________Relationship______________________________________
Address___________________________________________City_______________________, State__________, ZIP_____________
E-mail ______________________________________________________________________________________________________
Home Phone__________________________________________Work Phone_____________________________________________
Cell Phone____________________________________________Fax____________________________________________________
Date of Birth_____________________ Sex_________ Social Security Number____________________________________________
Referred By_______________________________________Phone _____________________________________________________
Primary Insurance_______________________________________ID____________________________________________________
Policy Holders Name ____________________________________DoB_____________________SSN_________________________
Secondary Insurance_____________________________________ID___________________________________________________
Policy Holders Name ____________________________________DoB_____________________SSN_________________________
Date injuries occurred___________________________________________________________
Were your injuries related to an Auto Accident Y N Workers Compensation Claim? Y N Other Y N
Carrier__________________________________________ Phone Number_______________________________________________
Claim Number________________________________________________________________________________________________
Adjuster or person to verify benefits______________________________________________________________________________
Phone Number_______________________________________
I authorize the release of any medical information necessary to process insurance claims and certify that the above information is true,
I further authorize direct payment to the provider of services for medical and surgical benefits, if any.
SIGNED:__________________________________________________________________ DATE:___________________________
GWINNETT BONE & JOINT SPECIALIST
GEORGIA KNEE & SPORTS MEDICINE
GWINNETT ORTHOPAEDIC & SPORTS MEDICINE