SURGIX FITNESS CARE
User Registration Form
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Personal Information
First Name:
Middle Initial:
Last Name:
Street Address:
City:
Cell Number:
Work Number:
Date of Birth:
Age:
Gender:
Male
Female
Marital Status:
Select
Single
Married
Divorced
Widowed
Email:
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Emergency Contact Information
First Name:
Last Name:
Relationship to Patient:
Select
Spouse
Parent
Child
Sibling
Friend
Other
Please specify relationship:
Address:
City:
Postal Code:
Primary Phone:
Secondary Phone:
Email:
Same address as patient
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Health Information
General Overall Health:
Excellent
Good
Fair
Poor
Activity Level:
Highly Active
Active
Medium
Low
Height:
Weight:
Shoe Size:
Do you have a latex allergy?
Yes
No
Do you have any other allergies?
Yes
No
Please specify allergies:
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Physician Information
Referring Physician Name:
Street Address:
City:
Phone Number:
Primary Physician Name:
Street Address:
City:
Phone Number:
I authorize the release of any information necessary to provide service for prosthesis evaluation.
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Payment & Amputation Information
Payment Method
Do you have insurance?
Yes
No
Insurance Company:
Will your employer be financing your treatment?
Yes
No
Will you be self-financing your treatment?
Yes
No
How do you plan to finance your treatment?
Do you require financing from any organization?
Yes
No
Please select the relevant option:
Government Funding
Jamaica Council for Persons with Disabilities
Other
Amputation Information
Amputation Location:
Right Side
Left Side
Bilateral
Amputation Type:
Date of Amputation:
Reason for Amputation:
Patient Signature:
Clear
Date:
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