Patient Forms

This is a lengthy and extensive medical document that is required for your start of care.

All patient forms, paperwork and instructions listed below are password protected. Please call the office for the password to open and download files. Thank you!

Patient Packet

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 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.

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.

All patient forms, paperwork and instructions listed below are password protected. Please call the office for the password to open and download files. Thank you!

Informed Consent Packet

Informed Consent Opioid Therapy Acute Pain Med Contract Chronic Pain Med Contract

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.

This document is a form that will allow us to obtain and / or share medical records with whomever you designate.

All patient forms, paperwork and instructions listed below are password protected. Please call the office for the password to open and download files. Thank you!

Medical Records Release