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Journey Orthopaedic Institute
Patient Intake Form
Please complete all fields below
First Name
*
Last Name
*
Date of Birth
*
Gender Assigned at Birth
*
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Male
Female
Phone Number
*
Email
*
Communication Preferences
I consent to receive email communication
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I consent to release my medical information to Journey Orthopaedic Institute
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What brought you in today?
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What is the main reason for your visit today?
Ok, got it. Give us some more information on what's going on.
*
Please describe the history and details of your current medical concern.
Current Pain Level:
0/10
No Pain
Worst Pain
Provider Preference
Best Match
First Available
Christie B. Smith, PT
Justin T. Smith, MD, FAAOS, FAANA, ABOSD
Rebecca Tucker, ATC
Choose a specific provider, or let us find the best match for you
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