Iowa (563) 322-0971
Illinois (309) 762-3621
Illinois (309) 762-3621
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.
If you are a new patient to ORA Orthopedics, please download, print and complete the following forms and bring with to your appointment.
If you are a new spine patient to ORA Orthopedics and have an appointment with Dr. Michael Berry, please download, print and complete the following forms and bring with to your appointment.
If you are a new spine patient to ORA Orthopedics and have an appointment with Dr. Myles Luszczyk, please download, print and complete the following forms and bring with to your appointment.
If you are a new pain center or pain management patient to ORA Orthopedics and have an appointment with Dr. Sanjay Sundar or Dr. Asad Hashmi, download, print and complete the following forms and bring with to your appointment.
ORA Orthopedics requires that a parent or legal guardian accompany any minor (under the age of 18) to the first appointment. This allows for proper discussion of treatment options and informed consent. If for subsequent visits a parent or legal guardian cannot accompany the minor an Authorization to Treat a Minor Child in Absence of Parent form must be completed, signed, witnessed and sent with the minor or person accompanying the minor to the appointment. All copayments are due at the time of service, so the minor or accompanying adult should be prepared to make any payments due.
If you are requesting ORA to process your liability claim, whether it is from a personal injury claim or motor vehicle accident, download, print and complete the following form and bring with you to your appointment or fax to the individual noted on the form.
