Patient Intake Form Name*Date of Birth* Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Sex*MaleFemaleMarital Status*MarriedSingleDivorcedWidowedCell*Email* Social Security Number*Drivers License NumberRaceLanguageEmployerWork NumberOccupationSchool You AttendEmergency Contact*Emergency Contact Phone*Relationship to Patient*Height - Feet*12345678Height - Inches*01234567891011Weight*Primary Care DoctorPrimary Care Doctor PhonePharmacyPharmacy PhoneWhat physician referred you to us? If none, please type none.*I, being of legal age (18 or older), understand that I am responsible for all accounts with All American Orthopedic including any rendering Physician that may provide services during my visit. I authorize the release of information to my insurance company.Patient/ Parent/ Legal Guardian Signature*Date* Physician Ownership Disclosure FormDuring the course of your physician/ patient relationship with Drs Holt, Jaglowski, Higgs, Weinberg, Juarez, Muffoletto or their representatives at All American Orthopedic & Sports Medicine Institute, you may be referred to any of the following: Alliance MRI - 17490 Hwy 3, Webster, TX 77598 * Houston Physicians Hospital - 333 N Texas Ave #1000, Webster, TX 77598How did you hear about us? Friend/Family Physician Referral Magazine Commercial Radio Any of these facilities may be out of network with your healthcare provider. You have the right to choose alternate healthcare providers. You will not be treated any differently by your Physician, the Physician's staff, or the facility. A list of specific Physician ownership and Physicians immediate family members ownership is available upon request. This information is being provided to you to help you make an informed decision about your healthcare.Patient Name*Signature*Date* This iframe contains the logic required to handle Ajax powered Gravity Forms.