Appointments

We see patients by appointment Monday through Friday between 9am and 4:30pm Call 254-8800 to schedule your visit, preferably in the late morning or early afternoon when our phones are least busy. You may email us your appointment preference. Click on email at bottom of web page. Thanks

Cancelling an Appointment

If you are unable to keep your appointment please notify our office 24 hours prior to the appointment, otherwise an office charge will be accrued.

Payment

We expect payment at the time of your visit (unless special arrangements have been made with us in advance). You may pay in cash or by check, MasterCard or VISA.

REGISTRATION FORMS    FILL OUT BOTH FORMS    PLEASE AND BRING OR
FAX TO OUR OFFICE OR EMAIL THE FORMS TO       mccain@attglobal.net

MCCAIN ORTHOPAEDIC CENTER
1812 Hampton St
Columbia, S.C.  29201   8032548800    8032549130 (Fax)

REGISTRATION FORMSA

PATIENT DEMOGRAPHICB

HISTORY FORM FORM 1

Name _________________________________ Date ______________

Describe the Problem you are seeing the Doctor for today ________________________
____________________________________________________________________

If this is due to an injury,  How did it occur, When and Where   ____________________
____________________________________________________________________

Have You had any Treatment for this Problem  _____Yes____No   Clinic/Doctor______

Have You had any X-rays for this problem _____Yes ____ No

If Yes , where? __________________________  Are you possibly pregnant___Yes____No

Did you bring any X-rays with you today ____Yes                    Review of Systems ________                                                                     Gyn__MSK__GI__GU__

Please list any medications you are presently taking:                         

1)_______________  3)  ___________________ 5)_________________

2)_______________  4) ___________________ 6)_________________

Please List all Surgeries, Hospitalizations, Or any medical problems or medical diagnoses

1) _______________ 4) ___________________ 7) ________________

2) _______________ 5) ___________________ 8) ________________

3) _______________ 6) ___________________ 9) ________________

Are you allergic to any medicines ______Yes ____NO

Please List

1) ____________ 3) _______________ 5) _______________

2) ____________ 4) _______________ 6) _______________

Who is your referring Doctor ? ________________________________

Who is your Regular Doctor ?  ___________________________________

How did you choose our practice ?  Friend__ Family__Columbia Yellow Pages__
Physician__Hospital Referral Service__Managed Care Plan__ Emergency Room __
S.C. Supernet__ Previous Patient__ Voc Rehab__ High School__ Lexington Yellow Pages__
Batesburg Yellow Pages__ Camden Yellow Pages__ Newberry Yellow Pages__ Winnsboro Yellow Pages__ Orangeburg Yellow Pages__
 

PATIENT DEMOGRAPHIC & INSURANCE INFORMATION FORM 2

MCCAIN ORTHOPAEDIC CENTER

Patient Information    Name                                                Date ______________

___Mr.      ___________________________________      Male _________
___Mrs     ___________________________________.
___Miss    ___________________________________       Female ________     Age__

Birthdate ________________________Single___Married___Divorced___Widowed___

Name of Person Legally Responsible  ______________________________________
    (If patient is a minor, name of parent or guardian

School __________________________________________________

Home Mailing Address __________________________________________________
____________________________________________________Home Phone __________

Patient Social Security No. ___________________________Drivers License No._________

Patient Employed By  _______________________________Occupation_______________

Business Address __________________________________Bus Phone _______________

Name of Spouse or Parent _________________________Age___ Birthdate____________

Social Security No. __________________Employed by ___________________________

Business Address ______________________________Business Phone_______________

Nearest Relative Not Living With You _____________________Phone _______________

Do you have Medicare?  No___ Yes____ Number ________________________________

Do You have Medicaid? No___ Yes___  Number _________________________________

Name of Insurance Company_____________________  Insured's Name_______________
                                                                                         Policy or group# _____________
Address ____________________________________   Copayment Office ___________
                                                                                         Copayment Surgery __________
In Whose Name is Insurance? ____________________   Coinsurance _______________
                                                                                          Deductible _________________
Is This Workmens Compensation? _________________

RELEASE AND ASSIGNMENT:  I hereby consent to any necessary medical treatment for myself, child, or the above named minor, for whom I am legally responsible.  The release of medical information to any insurance carrier, and direct payment to McCain Orthopaedic Center for any treatment or examination rendered is authorized.  I hereby acknowledge and accept final responsibility for payment of  charges for medical service rendered.
Signed ____________________________________________Date__________________