Lehigh Valley Orthopedic Institute–Dickson City

Patient Forms

334 Main Street
Dickson City, PA 18519-1668
United States

Fax
(570) 307-1770

Patient forms

To save you time when visiting our office, we have conveniently included a list of our patient forms below. Simply download and print the form, complete the questions and bring with you to the office.

Opens in new tab Financial Policy
Opens in new tab Patient History
Opens in new tab Patient Authorization for Release of Information
Opens in new tab Notice of Privacy Practices
Opens in new tab Spine History Questionnaire (Dr. Gillick, Dr. Henderson)
Opens in new tab Rheumatology Questionnaire (Dr. Grady)
Opens in new tab Hip Questionnaire (Dr. Schmaltz and Samujh)
Opens in new tab Knee Questionnaire (Dr. Schmaltz and Samujh)
Opens in new tab Shoulder and Elbow Questionnaire (Dr. Tracy)