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Patient Registration Form

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For Office Use Only

Patient Registration Form

When were you treated by the medical provider?

Patient Information



Billing and Insurance Information

Patient Health History

Mark if you have been diagnosed with any of the following:

Mark family members who have been diagnosed with any of the following:

Have you experienced any of the following:

Do you use any of the following:

Today's Problem

I hereby agree to be treated by Garden State Orthopaedic Associates, P.A. (Dr. Kenneth A. Levitsky, Dr. Douglas S. Holden, Dr. Adam D. Bernstein, Dr. Steven Shamash, Dr. Brian Van Grouw, Dr. Ryan Cassilly, Dr. Frederick Fakharzadeh, Dr. Erik Zachwieja, William Thomson, PA-C, or Bryan D. Sheldon, PA-C, Long, Bui-Le PA-C, Jeffrey Lee, PA-C)

I acknowledge full responsibility for the payment of services rendered to me and agree to pay for such services in full, regardless of insurance or third party involvement, unless otherwise prohibited by law • I have been informed as to my in-network or out-of-network status prior to my visit • I authorize the practice to release to my insurance company or any of my third party payors any information needed to determine my insurance coverage • I authorize you to file claims with all insurance and third party carriers and further authorize and direct my insurance benefits to be paid directly to Garden State Orthopaedic Associates, P.A. 28-04 Broadway, Fair Lawn, NJ 07410 Tax ID #222814819

Please note that our office makes supplies available for your convenience. All medical supplies must be paid for at the time of your visit.

Patients are responsible to pay a 1% per month finance charge on all unpaid balances which exceed 30 days.

I verify the accuracy of the above information and authorize release of information as provided.