VIRTUAL VISITS / TELEHEALTH

• Telehealth Consent Form (Electronic)

Telehealth Instructions

• Microsoft Teams
• HealthHere

Dr. Gross’ Forms

• https://www.grossortho.com/forms

• Private Pay Agreement for Medicare Patients

Dr. Fowble’s Forms

• New Left Hip Questionnaire (Fowble)
• Right Hip Questionnaire (Fowble)
• Hip Questionnaire: 6 wk & 1 Year Follow-up (Fowble)

Dr. Lamotta’s Forms

All Patients will need to complete 2 forms for each visit.

New Patients

• New Orthopedic Spine Packet (electronic)
• Spine Evaluation Form (printable for completion at home or in the office) 

Returning Patients

• Follow-up Form for Return Visits with Dr. LaMotta (electronic)
• Spine Evaluation Form (printable for completion at home or in the office) 

Surgery Instructions For

• The Surgery Center at Midlands Orthopaedics and Neurosurgery
• Prisma Health Baptist
• Prisma Health Parkridge

APPOINTMENT REFERRALS

• Referral Form
• Physician Referral for ESI
• MRI Referral Form

THERAPY FORMS

• Low Back Pain Disability Questionnaire
• Billing and Payment Information
• Lower Extremity Functional Scale (LEFS)
• Neck Disability Index
• Quick DASH