New Patient Paperwork
Prepare for Your Visit
In order for us to prepare appropriately for your visit, we ask that you take the following steps in preparation for your appointment.
- Obtain a referral from your primary care physician, if your insurance requires one (most do not).
- Please bring the referral with you or arrange to have your physician's office to email or fax our online form it to Oklahoma Joint Reconstruction Institute.
- Obtain pertinent medical records, X-rays, MRI, or scans previously completed for this condition and hand carry to your appointment.
- Please note that any X-rays, MRI or scans performed at OSSO, Community Hospital (North or South) and Northwest Surgical Hospital are available to OJRI (including the reports) and it is not necessary for you to contact these facilities to obtain records.
- All outside x-rays should be hand carried to your appointment. It is your responsibility to obtain any imaging or previous medical documentation Dr. Jacob may need upon seeing you.
- Complete the Patient History Form and bring it to your appointment (click here to obtain form on-line)
- Review and sign the Financial Policy and bring it to your appointment (click here to obtain form on-line)
- Review the Notice of Privacy Practices (click here to review)
- Review and sign Patient Consent and bring it to your appointment (click here to obtain form on-line)
- Bring your insurance card(s) to your appointment.
- Bring your deductible or insurance co-payment which is due at the time of service.
- For your convenience we accept MasterCard®, Visa®, Discover®, Care Credit, and American Express®.
- Please remember that all patients under the age of 18 must be accompanied by a parent or guardian.
Informed Consent Documents
These are several documents that inform you of your risks associated with your treatment. These include surgical risks, COVID risks, implant rejection, telemedicine, and remote patient monitoring.
Letters of Medical Necessity
These are documents that may be required by your insurance company for durable medical equipment such as braces, ambulatory aides, sequential compression devices, continuous passive motion machines, ice machines, ect.
Medical Records Release
This document is a form that will allow us to obtain and / or share medical records with whomever you designate.
- Acute Pain Agreement
- Authorization for Treatment
- Chronic Pain Agreement
- Disclosure of Physician Ownership Notice to Patients
- Informed Consent for Telehealth Treatment
- New Patient Ortho Intake
- OPIOID Therapy Informed Consent
- Patient Demographics
- Prescription Policy
- Release of Info
- Remote Patient Monitoring
- SOAPP Version 1.0 - SF