Patient Forms

Medical History Forms

Completing the necessary medical history forms before your appointment will ensure the most efficient visit. Please click on the link below, complete the form, and print.  Bring the completed form to your appointment.

New Patients:

New Patient Medical History Form

Patients being seen for a neck or back condition scheduled with – Dr. Scott Collins or Dr. Michael Berry:

Back / Spine Medical History Form

 

Medical Record Request Forms

To request a copy of your medical records, please complete the following:

  1. Click on the following link and print the Authorization for Use and Disclosure of Patient Health Information Form.
  1. Complete, Sign, and Date Form. Include a picture ID of patient requesting medical records.
  1. Return Form to ORA Orthopedics by:
  • Fax to ORA Medical Records: (563) 324-0615 or (309) 762-3690

or – 

  • Hand Deliver to any Clinic Location

or – 

  • Mail to ORA Orthopedics
    Medical Records Department
    2300 53rd Ave.
    Bettendorf, IA 52722

Important:  A picture ID of patient requesting medical records must be included when faxing or mailing the medical release form.  If the medical release form is hand delivered to a clinic location the patient must present a picture ID.

Please allow 7 to 10 business days to complete your request.  Once the completed release form with patient picture ID is received in the Medical Records Department, your request will be processed.

*Please note: the medical history forms above require the latest version of Adobe Acrobat Reader. Click this link to be taken to Adobe’s website to update.