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Forms for Patients

Patient Demographic Information

– General patient intake information

Acknowledgement of HIPPA Privacy Practices

– Our offices adhere to all aspects of HIPPA privacy laws. A copy of these are available at each office.

Authorization to Release Medical Information

– JP&O will never release medical or appointment information to any persons with prior authorization from the patient.

Consent to Treat a Minor Child

– JP&O must have parental or guardian consent to treat any minor.

Consent to Photograph and Video

– JP&O Labs utilize cameras and video for patient care. No images or information is shared for use other than medical research or insurance purposes.

Surveys for Patients

Patient Satisfaction Survey for General Care

– General patient care survey

Patient Satisfaction Survey for Orthotics

– Patient survey for orthotic devices, products and care

Patient Satisfaction Survey for Footwear

– Patient Survey for footwear devices, products and care

Patient Satisfaction Survey for Prosthetics

– Patient survey for prosthetic devices, products and care

Patient Satisfaction Survey for Compression Garments

– Patient survey for compression garments and care

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