Patient Forms & Instructions


 

Are you tired of being handed a clipboard full of forms when you check in?

We appreciate that your time is valuable and want to make your experience with us as simple and efficient as possible while providing the highest level of care. For your convenience, the links below provide important documentation and forms that can be reviewed and completed prior to your appointment.  Please download and complete the applicable forms.  Once completed, please print and sign them.  You can then bring the completed and signed forms to your appointment or you can fax them to our office at (315) 685-7549.


New Patient Forms

Patient Registration Form
Asks for general information regarding your name, contact information, insurance information, Primary Care physician, any referring provider information, etc.

Medical History
Includes questions about your medical and family health history, medications, allergies, your injury and any prior treatment you may have received.

 

Financial Policy & Acknowledgement
Describes our billing, insurance and collection policies and requires your signed acknowledgement of your financial responsibilities for services provided.

Privacy Practice & Acknowledgement
Describes how medical information about you may be used and disclosed. Requires your signed acknowledgement that you have reviewed the Notice of Privacy Practices of Victory Sports Medicine & Orthopedics.

 

Additional Forms


Workers’ Compensation Injury Report
You will need to complete this form if you have a work injury that will be covered under your employer’s workers’ compensation insurance.


Motor Vehicle Injury Report
You will need to complete this form if you have an injury that was caused by a motor vehicle accident and will be covered by motor vehicle insurance.


Motor Vehicle Assignment of Benefits
You will need read and sign this form if you have an injury that was caused by a motor vehicle accident and will be covered by motor vehicle insurance.  This form will allow Victory Sports Medicine & Orthopedics to submit your medical expenses (claims) to the motor vehicle insurance company.


Consent for Treatment of a Minor by Parent or Legal Guardian
This form will need to be completed if, for some reason, you are unable to attend your child’s appointment and you would still like them to be seen and treated.


Permission for Another Individual to Authorize Treatment
This form will need to be completed if you wish to grant another individual permission to authorize treatment for your child.

Location
Marc P. Pietropaoli, M.D.
791 West Genesee Street
Skaneateles, NY 13152
Phone: 315-293-3778
Fax: 315-685-7549
Office Hours

Get in touch

315-293-3778