Phillips Ambulatory Care Center: 10 Union Square East, Suite 3M, New York, New York 10003
212.844.6735
 

Patient Forms

Beth Israel Orthopedics and Sports Medicine provides our patients with office forms on this website for your convenience. We recommend you print and fill these forms out at home to save time while in our office.

Note: These files are in PDF format. If you do not have Adobe® Reader® on your computer, you can download it for free by clicking here or on the Get Adobe Reader icon.

Forms Required For All New Patients

All new patients with appointments should complete these forms and bring them to your initial visit to provide us with information about medical conditions.

Forms Required For Some New Patients

Patients covered by workmen’s compensation or no fault, please complete this additional form prior to your office visit.

All new patients with Shoulder problems should complete this form and bring them to your initial visit to provide us with additional information specific to your shoulder condition.

Returning Home Instructions

This pre-surgical packet has instructions on preparing for surgeries, medications to discontinue, what to expect on day of surgery as well as post-operative instructions.

Other Forms

Please use this form to authorize Beth Israel Orthopedics & Sports Medicine to release medical information or when requesting access to medical records.

Seven days prior to the anticipated surgical procedure a complete history and physical examination including past medical history, a list of present medications with dosage and frequency, allergies, and a review of systems are required. Please have your primary care physician complete the form. Kindly include all pertinent test results as well.

This notice describes how medical information about you may be used and disclosed and how you can get access to this information.

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