Appointment request?

Address

Street Address

City

State

Country

Home zip code

Reason for Visit:

Knee:

Where exactly is the knee pain?

Please point to the exact knee area of pain with one finger, take a photo, and upload it below.

What activity or movement reliably brings the pain on?

What could you do with your knee before that you now find difficult or painful?

mechanical symptoms

Shoulder:

Where exactly is the shoulder pain?

Please point to the exact shoulder area of pain with one finger, take a photo, and upload it below.

Do you feel catching, clicking, weakness, or instability?

What shoulder activities were you able to do before that are now difficult or painful:

weakness

Hip:

Where exactly is the pain?

Please point to the exact area of pain with one finger, take a photo, and upload it below. (copy)

Elbow:

Where exactly is the elbow pain:

Please point to the exact area of elbow pain with one finger, take a photo, and upload it below.

What specific activity or motion brings the pain on?

Did this start Do you notice catching, locking, stiffness, or loss of motion? with an event, or gradually over time?

Elbow: What can’t you do now that you could do before?

Spine:

Spine: What can’t you do now that you could do before?

Orthobiologics:

What specific problem are you hoping biologics will help—and what have you already tried?

What outcome matters most to you: pain relief, function, performance, or avoiding surgery?

Are you interested in following a structured recovery and loading plan after the injection?

goals

Cash: self-pay pricing acknowledgment

I understand and agree

Commercial: eligibility & deductible responsibility

I understand and agree

Primary Insurance Carrier:

Is the patient the primary policyholder?

Yes

No

If NO, please answer the following:

Relationship to subscriber

Spouse

Child

Other

Please upload a photo of the FRONT of your insurance card:

Card images reduce eligibility errors by >80%.

Please upload a photo of the BACK of your insurance card

Has your insurance required referrals or authorizations for specialist visits in the past?

Yes

No

Not Sure

Primary Care Physician (PCP) name (if HMO or referral-based plan)

Name + Practice (if known)

Auto/WC: authorization, delays, lien acknowledgment

I understand and agree

Mechanism (MVC, fall, lifting, repetitive use)

Please upload a photo of the FRONT of your Driving License:

Please upload a photo of the BACK of your Driving License:

Communication Consent:

How may we communicate with you? *

SMS/Text (Appointment reminders, care coordination)

Email

Phone Calls

Voicemail

By selecting text messaging, I consent to receive healthcare-related SMS messages from SIGMA Orthopedics & Sports Medicine. Message and data rates may apply. I may opt out at any time by replying STOP.

I acknowledge receipt of the SIGMA Notice of Privacy Practices

I authorize SIGMA to use and disclose my health information for treatment, payment, and healthcare operations

In your own words, tell us what problem you are having.

When did this start, and what were you doing when it began?

Quality (sharp, dull, catching, instability)

Aggravating / relieving factors

Functional limitations

Details:

Police report / claim number

If Other (Past Medical History)

Please list any prior surgeries and approximate dates.

Please list all current medications, including supplements

Allergies

No known drug allergies

Medication allergy (reaction required)

SOCIAL & FUNCTIONAL HISTORY

Functional demands (work, sport, caregiving)

GOALS & OUTCOME EXPECTATIONS

What would success look like to you in 3–6 months?

Acknowledgement

I attest that the information provided is accurate

I understand this information will be used to guide my care