Forms | Patient Registration | Scott L. Sledge, MD

Patient Forms

For your convenience, our forms can be downloaded on your computer and printed out for you to complete at your leisure or can be completed and submitted online. If you choose to complete the form at home please ensure to bring the completed form to your appointment. Always remember to bring your identification and insurance information to the appointment. Let us know if you have any questions or concerns and we would be more than happy to assist you. We look forward to seeing you soon!

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Online Forms

Downloadable Forms (PDF)

Medical Records Release(.pdf)

Privacy(.pdf)

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I. Patient Information

First Name	MI	Last Name
Address	Apartment #	City/State/Zip
Home Phone	Work Phone	Cell Phone
Social Security #	Age	DOB (mm/dd/yyyy)
Gender Marital Status	Employer	Employer Address
Employer City/State/Zip	Referred By	Primary Care Physician
Emergency Contact	Relationship to Patient	Phone
		Continue to next section

II. Guarantor (if patient is a minor)

Name	Employer	Social Security #
DOB (mm/dd/yyyy)	Work Phone	Cell Phone
		Continue to next section

III. Insurance Information

Please bring insurance card(s) and photo ID to the office
Insured's Name (if different from patient)		Insurance Carrier
Insured's DOB and SS#	Secondary Insurance
		Continue to next section

IV. Medical Information

What are you being seen for today?
Is this a work related injury? Yes (please see receptionist) No		Is this related to an auto accident? Yes No
If due to accident, type of accident?		If due to accident, date?
I certify the above information is correct. I authorize Scott L. Sledge, MD and Ashley Book, PA of Scott L. Sledge, MD, PA to release or request medical information necessary to process health insurance claims. I authorize payment of my medical insurance benefits to Scott L. Sledge, MD, PA. I understand that I will be responsible for payment at the time services are rendered. This includes any outstanding deductible and/or coinsurance. Our office does not file third party claims. Payment is expected in full, Scott L. Sledge, MD, PA will provide itemized receipts for services provided for reimbursement of third-party billing. Please make a selection. ***If you are referred to North Central Ambulatory Surgery Center, we required by law to inform you that Scott L. Sledge, M.D.,PA has ownership interest in the facility and may receive remunerations indirectly for services rendered.

Dr. Scott L. Sledge, MD | Orthopaedic Surgeon - San Antonio, Texas

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