Patient Forms

Use this page to download NEW KNEE PATIENT forms. All files are in Adobe Acrobat format. If you do not have the Adobe Acrobat reader, you can download it here.

Please contact Lee Webb N.P. with any initial questions about our practice. Lee is Dr. Gross' assistant in the office and surgery. She is very knowledgeable about all aspects of this practice. She will guide you through the process or answer any preliminary questions that you have:

Lee Webb, N.P.    E-mail: LeeW@midlandsortho.com
                             Cell phone: (803) 331-6894

If you have no questions, please just follow the protocol below and FED EX the packet to:

Dr. Thomas P. Gross
Midlands Orthopaedics
1910 Blanding St.
Columbia, SC  29201

We will call you when we receive your packet. Dr. Gross will usually call you personally within 2 weeks of receiving the information.

NEW KNEE PATIENT FORMS:

Required for initial evaluation:

1. Your most recent x-rays (must be within the last 6 months; we prefer them on a disc), we do not need MRI films or CT scans
2. Knee XR request letter (Only to obtain a new XR if yours is out of date)
3. Patient information form
4. New patient knee questionnaire
5. Medical history form
6. Copy of your insurance card: front and back

Additional information needed to schedule surgery:

1. Mission statement and disclosure form
2. Privacy information form
3. Financial policy form
4. CBC (complete blood count) request; or your PCP can order this
5. Copy of your insurance card: front and back
6. Please read Insurance information carefully
7. Financial policy form
8. Authorization and acknowledgements form
9. HIPAA privacy authorization form