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Dr Moore - Home Page About Dr. Moore A Better Knee Preserving Joint Health
   

Seniors

 


If you are concerned about a chronic joint condition or experience joint pain (specifically a knee or hip) and are not currently seeing an orthopedic doctor you may use this form to submit details of your condition. A member of the clinic staff will respond via email with suggestions or offer arrangements for a clinic visit.

Internet forms should not be used to communicate emergency information.

Schedule requests and New Patient forms are processed the following clinic day, and are not a substitute for urgent or emergency care. If you are experiencing an emergency please use local emergency services or dial 911.

This form is used to assist the clinic staff to do a cursory screening of your prevalent condition and determine best next steps. It is not intended to replace an in-person visit with a medical doctor. The information you submit electronically can only be reviewed during business hours published on this web site. During office hours, you may contact the clinic by telephone at 253-833-7750

As a recipient of information from this web site, and as you submit personal medical information using this form, you are not establishing a doctor/patient relationship with any physician. Clicking the "Submit" button signifies your acknowledgement and agreement to these terms of use.

 
Name:  
Date of Birth:  
Male:  
Female  
Email:  
 @ .
Please describe the reason   
you are seeking care:  
Date when your problems first began:  
If there was an injury did it happen at  
any of the following places?  
Work:  
Auto related incident:  
School:  
 
 
Have you ever had symptoms  
or an injury/condition like this before?
Yes:  
No:  
 
 
Have you ever been treated by  
another doctor or an emergency  
room for this injury?  
Yes:  
No:  
 
  
Have you had x-rays or MRI relating  
to this injury in the last six (6) months?  
Yes:  
No:  
 
 
Name of your medical or primary doctor:  
Were you referred to Dr. Moore  
by a health care provider?  
Yes:  
No:  
 
 
Please list all previous orthopedic operations:  
Please list all ALLERGIES, if none,  
please note "NONE KNOWN":  
Please list all medications you are now taking:  
Please list all nutritional supplements  
you are now taking: