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Fax: (817) 776-8154

 

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: 


Chief Complaint Information

*Chief Complaint: 

*Diagnosis Date or Date Complaint Began:   

*Current Symptoms including 1) Primary location of pain  2) Secondary location of pain  3) Primary disabilities associated with 
  your condition
 

*Treatment History:


*Have you had an MRI in the past 12 months?      Have you had an X-Ray in the past 12 months? 


Current Medications:

Please list your current medications OR upload a copy of your medication list OR Fax a copy to 817-776-8154
Be sure to include Name, Dosage, How often you take it, Reason for taking it and Date Started.

RMI will not evaluate anyone who does not submit a medications list.

Current Medications:


OR

  (Click here to upload your medication list.)

OR

  I faxed my medications list to 817-776-8154.  (Select this check box if you've faxed your medications list to us.)


*Nutritional Supplements:


*Are you currently taking Human Growth Hormone? 
If yes, how many injections per week and for how long? 

*Are you taking any anticoagulants like Plavix or Coumadin? 

*Have you had any steroid injections like cortisone in the past 3 months? 
If yes, what kind of shots did you receive and when did you receive them? 

*Have you ever had any kind of stem cell therapy 
If yes, please list when, where and what type of stem cells you received.



Social History

*Do you smoke cigarettes?  Cigars?  Pipe? 
If yes, how much per day? 

*Do you drink beer?  Wine?  Liquor? 
If yes, how much per day? 


Prior Surgeries

*Please list any prior surgeries and their dates (mm/yyyy).  Use “none” if you haven’t had surgery in the past.


*Do you have any metal plates or rods inside your body? 
If yes, please list details here:


Allergies

*Do you have any allergies to medications or other substances? 
If yes, please list medications, vaccinations and/or substances to which you are allergic:


*Please list any allergy medications you are taking.  If you are not taking anything, use "none":



Cancer

*Have you ever been diagnosed with any type of cancer, especially bone marrow cancer? 
If yes, please list type of cancer, month and year diagnosed and current status:


If you’ve had a recent mammogram, please list the date (mm/yyyy) and the result. 

If you’ve had a recent PSA test, please list the date (mm/yyyy) and the result. 


Diabetes

*Are you diabetic?      If yes, are you on insulin? 


Neurological

*Vision worsening?      *Black spots in field of vision?      *Uncontrollable eye movements? 

*Muscle weakness?     *Muscle wasting?      *Difficulty Walking? 

*Decreased hand strength?      *Fainting?      *Speech Problems? 

*Involuntary muscle twitching?      *Stiff or rigid muscles that affect walking, movement or speech? 

*Overactive or over responsive reflexes?      *Underactive or under responsive reflexes? 

*Depression?      *Memory loss?      *Sleep disturbances?      *Dizziness? 


Pulmonary

*Do you have asthma?      *Chronic bronchitis?      *Chronic cough? 

*Emphysema?      *Tuberculosis? 


Cardiovascular

*Do you have problems with blood circulation?      *Leg cramps?      *Tired feeling in legs? 

*Swollen ankles?      *Varicose veins?      *Tingling sensation in arms and legs? 

*Tingling sensation in hands and legs?      *Do you have any ulcers or open wounds on your body? 

*Hypertension / high blood pressure?      *Do you have congestive heart failure?  

*Do you have coronary artery disease?       *Have you had a heart attack?  

*Have you had a stroke or transient ischemic attack (TIA)?  


Gastrointestinal

*Do you suffer from acid indigestion?      *Do you suffer from bloating? 

*Stomach or intestinal ulcers? 
If yes, please list type(s) and date(s) diagnosed:

     
*Recent loss of appetite?      *Recent rapid weight gain?      *Recent rapid weight loss? 

*Have you had upper GI endoscopy?      If yes, when (mm/yyyy)? 

*Do you have hepatitis?  A   B   C      *Gall bladder problems? 

*Unusual yellow skin color (jaundice)?      *Recurring diarrhea? 


Upper Respiratory

*Chronic Sinusitis?      *Allergic sinus problems?      *Chronic allergic rhinitis? 

*Sinus headaches?      *Chronic colds? 


Rheumatic Screen

*Do you have rheumatoid arthritis?      *Soft tissue rheumatism?      *Joint pain? 

*Back pain?      Other rheumatic condition(s)? 


Endocrinological

*Overactive thyroid?      *Underactive thyroid?      *Adrenal gland dysfunction? 

Have you started menopause?      Other endocinological conditions? 


Other Illnesses or Conditions

*Please list any other illnesses or conditions you have (if you don't have any, list "None"):



Family History

*Low blood sugar?      *Diabetes?      *Thyroid problem? 

*Hormone problem?      *Cancer?      *High blood pressure? 

*Kidney problem?      *Leukemia?      *Arthritis? 

*Prostate problem?     *Mental disorder?      *Anxiety? 

*Lung problem?      *Heart problem?      *Stroke?     Fatigue? 


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 consultation.

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.  If you have insurance, it will be billed. You are responsible for any co-payment that is required by your policy. 




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

Rev. 12/22/2014