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Patient Medical Health History

Thank you for using My Crystal Clinic to access your very own secure patient medical health history form!

To ensure that we have an accurate health history, we ask that you complete this one-time through our secure link to the right.

Your medical health history process will include a series of questions related to the categories below:

  • Your Identification Information -- Name, Address, Birth Date
  • Medical History
  • Surgical History
  • Social History
  • Medications
  • Pharmacy (Address, Phone Number)
  • Allergies



Start Here Start Here

To begin your medical health history, please enter the numbers and letters in the box below to secure your unique log-in.

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After clicking the Continue button (above), you will provide responses to a series of questions that will help us to assess and determine your plan of care during your office visit. Please complete every answer on each page prior to clicking the 'Next' button.

Your thorough and complete answers on the next few pages will help our Physicians and staff provide you the excellent care you deserve.

Thank you for choosing
Crystal Clinic, Inc.!



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DISCLOSURE OF PHYSICIAN OWNERSHIP

Please carefully review the information contained in this notice so that you can make an informed decision regarding your care.

The CCOC supports initiatives that provide transparency in healthcare. We believe that corporate compliance, ethics, and integrity are essential elements in any healthcare organization. With the rising costs of healthcare, Americans are interested in physician, hospital, insurance company, supplier, and other industry relationships. As such, we have chosen to make certain disclosures to the public on arrangements that may be perceived as conflicts of interest.

According to Federal Regulations, Crystal Clinic Orthopaedic Center, LLC meets the definition of a “physician-owned hospital” under 42 CFR 489.3. The hospital is owned, in part, by physicians who may be providing your care. A list of those physicians can be provided for review upon request.

You have the right to choose the provider of your health care services. Although we believe that Crystal Clinic Orthopaedic Center will be able to meet your needs, you have the option to use a facility other than Crystal Clinic Orthopaedic Center. You will not be treated differently by your physician if you choose to use a different facility; however, your physician may not be able to perform your procedures at an alternative facility if he or she does not maintain privileges at that facility. If desired, your physician or another staff member can provide information about alternative health care providers.

Crystal Clinic Orthopaedic Center is also required under Federal Regulations found at 42 CFR 489.20(w) to inform you how care is provided in case of an emergency when a physician is not on site. Crystal Clinic Orthopaedic Center, depending on the facility or circumstances, has established processes to either (1) launch a Rapid Response Team which includes a physician, or, (2) make a 911 emergency call.

If you have any questions concerning this notice, please feel free to ask your physician or any representative of Crystal Clinic Orthopaedic Center. We welcome you as a patient and value our relationship with you.

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Ebola Screening

Updated 10/16/2014 - 12 Noon

If you can answer YES to either of the following questions, do not use this form. Call our offices directly to arrange your appointment.

  1. Have you traveled to West Africa
    • Guinea
    • Liberia
    • Nigeria
    • Senegal
    • Sierra Leone
    OR,
    any other areas where EBOLA transmission has been reported
    CDC Ebola Outbreak Map
  2. Have had any contact with an Ebola case within 21 days of their symptom onset
OR

If you have … fever (100.4 F or higher), headache, joint, muscles aches, weakness, fatigue, diarrhea, vomiting, stomach pain and lack of appetite and bleeding.

Again, if you can answer YES to either of the questions, do not use this form. Call our offices directly to arrange your appointment.

Click here to return to the Crystal Clinic website
Click here to continue to the pre-registration forms