Ortho FASTtrack Pre-Registration Form

Thank you for choosing Palm Garden as your recovery solution!

To ensure a smooth transition into our Orthopedic Program, please complete the pre-registration form below, and a member of our Admissions team will schedule your pre-surgical tour.

PATIENT INFORMATION:
Date
MM slash DD slash YYYY
Patient Name
Address:
Phone Number
Please include your cell phone number
What is your gender?
- Male
- Female
Service you are signed up for:
- In-Patient Therapy
- Out-Patient Therapy
Payor Source
- Medicare
- Insurance
- Private
Insurance Provider:
PROCEDURE INFORMATION:
Your surgeon(s) name:
Surgery date:
Location:
Schedule Procedure(s):
- Knee Replacement
- Hip Replacement
- Other
If you clicked other, please note which procedure you are scheduled for:
Transportation needs (from hospital/follow up appointments):
Food Preferences?
Special needs?
EMERGENCY CONTACT INFORMATION:
Emergency Contact Name:
Emergency Contact Address:
Emergency Contact Phone:
Please include cell phone numbers
Additional Comments:
How did you learn about us?
For additional security, please type "PALM" in the box below:*
CAPTCHA
Email
This field is for validation purposes and should be left unchanged.

Δ

Skilled Nursing
Rehabilitation Services
Outpatient Therapy
Programs

Palm Garden of Pinellas ~ 200 16th Ave. SE ~ tel 727-585-9377 ~ contact.pinellas@palmgarden.com

Ortho FASTtrack Pre-Registration Form

PATIENT INFORMATION:

PROCEDURE INFORMATION:

EMERGENCY CONTACT INFORMATION: