Patient Forms

PLEASE READ THE FOLLOWING INSTRUCTIONS BEFORE PROCEEDING TO THE FORMS BELOW:

1. Use this page to download new patient and patient follow up forms. All files are in Adobe Acrobat format. If you do not have the Adobe Acrobat reader, you can download it here

2a. For new in-state patients, please schedule an initial office visit so that Dr. Gross can evaluate your joint. IN-STATE PATIENTS MUST BE SEEN IN THE OFFICE TO SEE IF THEY ARE A CANDIDATE FOR SURGERY. All intial forms will be available in our office, but in order to keep your visit brief, we recommend printing and completing the new patient packet before coming in.

2b. For new out-of-state patients, we will need ALL the materials from the new patient packet (see section I). If you would like to have a telephone consultation with Dr. Gross or need help putting together your "new patient" package, please contact Evelyn W at (803) 933-6170 or email at This email address is being protected from spambots. You need JavaScript enabled to view it..

Once complete, please FedEx the package to:

Thomas P. Gross M.D.
Midlands Orthopaedics, P.A.
1910 Blanding St.
Columbia, SC 29201

 

forms

New Patient Forms

Please submit all initial evaluation materials (please review the packet in its entirety, using the first page as a checklist) before your first visit. All section II forms are required before scheduling your surgery. If you are a new patient and would like assistance with preparing or submitting your new patient package, please contact Evelyn W at (803) 933-6170 or email at This email address is being protected from spambots. You need JavaScript enabled to view it. .

OUT-OF-STATE PATIENTS: When all information is submitted, Evelyn will send the completed file to Dr. Gross for review. Usually, he will be able to call you within 3 weeks of receiving your information. Please be alert to calls from a blocked phone number or from any phone # with an 803 area code because Dr. Gross will call from home, the office, or the hospital.

I. For initial evaluation (choose one):
  1. New hip patient packet
  2. New knee patient packet
II. Information needed to schedule surgery:
  1. Mission Statement and Disclosure Form
  2. Privacy Information Form
  3. Financial Policy Form
  4. CBC Request (your PCP can order this)
  5. Please read through Insurance Information carefully
  6. Authorization and Acknowledgement Form
  7. HIPAA Privacy and Authorization Form

*Section II forms (not necessary for intial evaluation) ARE REQUIRED PRIOR TO SCHEDULING SURGERY.

Follow-Ups

For a postoperative FOLLOW-UP evaluation, please click one of the following links, download the form and mail to us along with your x-rays. Dr. Gross will review your material, have his staff send confirmation to you via email, and he will personally contact you ONLY to notify you of any concerns or at your request. If you have difficulties with this, please call us at 803-933-6127 or email us at This email address is being protected from spambots. You need JavaScript enabled to view it. .

  1. Hip Follow-up Package
  2. Knee Follow-up Package

Patient Care Paths

  1. Total Hip Arthroplasty Care Path
  2. Total Knee Arthroplasty Care Path

Surgical Risk Disclosure

  1. Hip Resurfacing Consent Form
  2. Total Hip Arthroplasty
  3. Total Knee Arthroplasty

Others

  1. Hospital Discharge Instructions
  2. Phase I Hip Exercise
  3. Phase II Hip Exercises
  4. Psoas Stretching Testimonial
  5. Postoperative Knee Exercises
  6. Disability Form
  7. Medical Records Request Packet

Located in South Carolina

Irmo Office

1013 Lake Murray Blvd.
Irmo, SC 29063

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Columbia Office

1910 Blanding St.
Columbia, SC 29201

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