Evergreen Orthopedic Center | Proliance Surgeons

Patient Forms

If you cannot access the form, please click on the Adobe icon. This will allow you to download this software, providing access to the forms.

Evergreen Orthopedic Clinic

New Patients

Provided below are various forms that require completion prior to your first visit. Please download the forms below by clicking on the name of the form. Complete and bring the forms with you for your first visit, along with any X-Ray, or MRI images that pertain to your symptoms.

• Notice of Privacy Practices
• Patient Registration
• Patient Health History
• Orthopedic Health History
• Authorization to Use or Disclose Health Information
• Authorization to Leave Personal Health Information by Alternate Means
• For Dr. Price & Dr. Freeborn Patients Only

Other Forms

• For Parents or Guardians – Consent to Treat Minors
• Patient's Rights & Responsibilities

Surgery Center

• Patient Survey
• Patient History
• Incident Report
• Regence Incident Report

Eastside MRI

Choose the appropriate form to fill out and bring it with you to your MRI appointment.

• Spine Injuries
• All Other Musculoskeletal Injuries

Physical Therapy

• Notice of Privacy Practices
• Notice of Privacy Practices Acknowledgement
• Patient Information
• Financial Agreement
• Authorization to Leave
  Personal Health Information
  by Alternate Means