Patient name_______________________________ (please print)
Date of birth_____/_____/_______
Last four of SSN#______________
Details of injury
Date of injury ______/______/______
Where did the injury occcur?
How did the injury occur?
Was this a motor vehicle accident? YES NO
Did the accident involve another party? YES NO
Did this injury occur on the job? YES NO
Did you or will you be filing a worker's compensation claim for this injury? YES NO
At this time, is it anticipated that another party (other than you insurance plan, worker's compensation, or Medicare) will be responsible for the medical expenses related to this injury? YES NO
Signature of patient or guardian Date
James K. Baker, M.D.
Lone Star Orthopedics, PA
Please note: this form is not for on-line submission. Please print this page and bring this to the office for your visit.