New Patient Form

Patient Information
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Spouse or Guardian Information
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Who May We Thank for Referring You to Us?
Guarantor (Individual responsible for account balances)
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Medical History
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MEDICATION AGREEMENT & REFILL POLICY

As part of your treatment, our medical staff may prescribe medication for you. Many of these medications can have serious side effects if they are not managed properly. Your health and safety are very important to us, and we need your help to make sure your treatment follows our guidelines. If Topp Spine & Orthopaedics has any questions regarding your healthcare, including medications, we reserve the right to contact your other treating physicians and pharmacies. 

1.  I agree to follow the dosing schedule prescribed to me by my doctor.

2.  I agree to .11.e_y_eu: share my medications with others, nor will I sell or exchange my medications for any reason

3.  I agree to always keep my medications safeguarded and within my control.

4.  I agree to notify Topp Spine & Orthopaedics if I experience any adverse effects or dosage problems with my prescribed medications. I will not discard any unused medications. Before any new medication can beprescribed, I may be asked to bring any unused medications to Topp Spine & Orthopaedics for disposal.

5.  I agree that if I receive narcotic prescriptions from Topp Spine & Orthopaedics, l am not allowed to receive the same type of medication from other physicians without expressing consent or consultation with ToppSpine & Orthopaedics.

6.  I agree to use only one pharmacy for my pain-related medication unless extenuating circumstances prevent this from being possible. In this event, I will notify Topp Spine & Orthopaedics of all pertinent information pertaining to additional pharmacies, mail-order, or other sources.

7.  l understand that medication refill prescriptions involving narcotic pain medicine requires a scheduled office visit when my doctor is on duty in the office. Narcotic pain medication refills will not be called into a pharmacy, nor will they be increased over the telephone.

8.  I agree to keep all scheduled appointments. I understand that no medications will be given for canceled or no-show appointments. I understand that if I am more than 15 minutes late my appointment time, I will have to reschedule.

9.  I understand that medication refills cannot be made after hours, on weekends, or on holidays.

10.  I understand that I should not drive or operate heavy machinery while I am taking medications that may cause drowsiness or impaired cognitive function.

11.  I understand that I am solely responsible for the safekeeping of my medications and I must treat my medications as I would my money or valuable possessions. Topp Spine & Orthopaedics will have no obligation to replace LOST or STOLEN prescriptions or medications.

12.  I understand that abusive behavior or harassment toward any Topp Spine & Orthopaedics' staff will NOT be tolerated. Harassment includes, but is not limited lo, more than two (2) phone calls to the office in one business day.

13.  I understand that I cannot present to Topp Spine & Orthopaedics unannounced seeking medication refills.

14.  I understand that dealing with a forged or falsified prescription will result in immediate dismissal from Topp Spine & Orthopaedics. I understand that I may be dismissed from Topp Spine & Orthopaedics if I do not abide by the terms of this medication agreement.

By signing the agreement, you affirm that you have the full right and power lo be bound by this agreement and that you have read, understood and accepted these terms. No medications will be prescribed without acceptance of this agreement. 

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HIPPA AUTHORIZATION FORM 

I authorize Topp Spine & Orthopaedics to use and disclose my following protected health information (PHI) listed below for the purpose(s) listed elsewhere on this web page. 

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As of the above date, this authorization to use and disclose this PHI information expires ("End of the research study" and "none" is acceptable for authorization for research purposes). 

I understand that I have the right to revoke this authorization, in writing, at any time by sending such written notification to the practice's Privacy Officer at (office address or e-mail address). I understand that revocation is not effecting to the extent that my physician has relied on the use or disclosure of the PHI or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim. 

I acknowledge that I have received and understand the notice of Privacy Practices and that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law. The use or disclosure requested under this authorization may result in direct or indirect remuneration to the physician from a third party. 

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