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Patient Application

Thank you for your interest in treatment at RMI.  In order to begin your evaluation, we need the following information.  Once we receive your medical history, a patient care coordinator will contact you to answer general questions and to guide you through the rest of the application process.  Most patients will be asked to submit a recent MRI disc and MRI written report in order to complete the evaluation.  Once we have received  your medical history, MRI disc, and MRI report you will usually be eligle to discuss your case with a doctor.

Items marked with (*) are required.

PLEASE NOTE THAT OUT-OF-POCKET EXPENSE FOR ONE MAJOR JOINT LIKE A KNEE IS AROUND $6,900 and includes: in-office evaluation, x-rays, bone marrow harvesting, bone marrow processing, anesthesia, amniotic tissue product, and precision injection using fluoroscopic imaging (C-Arm).

Caution:  
You must have javascript enabled in your browser to submit this form.  Otherwise, you will receive an error when you submit it.  Javascript is enabled on most browsers but if you are unsure and need instructions on how to enable javascript you will find them here: http://enable-javascript.com

BEFORE YOU COMPLETE THIS FORM:  RMI only treats ORTHOPEDIC CONDITIONS (knee, shoulder, hip, ellbow, back, etc.).  If you are applying for any condition or disease that is not orthopedic, you must apply to Dr. Riordan's clinic in Panama.  Please go to www.cellmedicine.com for more information.  People with conditions like autism, heart failure, cerebral palsy, MS, rheumatoid arthritis, spinal cord injury or an autoimmune disease should NOT apply here.  You should apply through www.cellmedicine.com 

Thank you.

 


How did you hear about RMI?      

Patient Information

*First Name:  Middle Name:  *Last Name: 

*Birth Date:        Age:  *Gender:      *Height:        *Weight:  lbs

*Address:  
*City:              *State/Province:  
*Zip Code:  (enter "none" if no zip code)     *Country:   

*Best Phone Number:    Home   Cell   Office 
Alternate Phone Number:    Home   Cell   Office 
Fax Number: 

*Email Address: 

Insurance Information

*Do you have health insurance?     Insurance Company Name:  
Subscriber ID:     Group ID (if any):  

*Pharmacy Information



Emergency Contact Information

*First Name:   *Last Name:   *Relationship: 
*Phone Number: 
Street Address: 
City:   State/Province: 
Zip Code:      Country: 

Medical HIstory and Information

*Reason for appointment:  
Please Describe:
 
*Have you been treated by another physician for this condition?     Physician Name:  
*Date of Injury or (approximate) date problem began:      

Symptoms (Check ALL that apply):
 Discomfort  

*Rate your current pain (0 = No Pain, 10 = Most Severe Pain):  

Previous Treatment (Check all that apply):
        (Type:   )  Other:  

*Drug Allergies:
          
Other Drug Allergies (Please list):  

Medications (Please list below):

  Medication Name   Medication Name   Medication Name


Have you had the following:  *Flu Vaccine:     *Pneumonia Vaccine:  

*Do you use tobacco?:     Packs per day:     Years:      *Do you use illicit drugs?  

*Do you use alcohol?:     How much?     *6 or more cups of caffeine per day?:  

*Occupation:     *Dominant Hand:  

Do you have a history of (check all that apply):
      


Other Medical History not listed:  

*Past Surgical History:  
If Yes, please list you past  surgeries (From left to right separated by commas):


*Have you ever had problems with anesthesia?:  

Family History (Please check all that apply):

  Diagnosis Father Mother   Brother   Sister   Family
  Hypertension
  Heart Disease
  Hyperlipidemia
  Stroke (CVA)
  Asthma
  Lung Disease
  Dementia
  Seizures
  Depression
  Kidney Disease
  Arthritis
  Blood Disorder
  Bleeding Disorder
  Diabetes Mellitus
  Tuberculosis
  Bone Cancer
  Lung Cancer
  Breast Cancer
  Prostate Cancer
  Renal Cancer
  Cancer NOS
  Others


   

Thank you for taking the time to complete this form.  Our medical team will review it within 3 working days and then our staff will contact you.

Online Evaluations: For a limited time, as a courtesy to our out-of-state and international patients, we provide a virtual evaluation.  Once we have received and reviewed all requested medical information, you may be eligible for a telephone consultation with a staff physician at no charge.  Applicants who are not eligible for treatment are not eligible for a free telephone consuly
tation.

Office Evaluations: Office evaluations are required for anyone living within the Greater Metropolitan Dallas/Fort Worth area. The cash price for this evaluation is $350.   



Do not click the Submit Form button more than once.  You will see a confirmation page once your form has been received.

Rev. 8/27/18