Loredo Hand Care Institute – Patient Intake Forms

Demographics

Please complete all fields marked with an asterisk.

* Required fields

Personal Information

Full Name *

Date of Birth *

Driver's License #

State (DL)

Home Phone

Mobile Phone *

Email Address *

Mailing Address

Street Address *

Apt / Unit #

City *

State *

ZIP Code *

Employment

Employer Name

Employer Address

Work Number

Occupation

Additional Information

Emergency Contact Name

Emergency Contact #

Primary Care Physician

PCP Phone #

Preferred Pharmacy

Pharmacy City / Phone

How Did You Hear About Us?

Financial Information

Primary Insurance

Insurance Company *

Insurance Tel #

Insurance ID #

Group #

Insured's Name

Insured's Date of Birth

Relationship to Patient

Secondary Insurance (if applicable)

Insurance Company

Insurance Tel #

Insurance ID #

Group #

Insured's Name

Insured's Date of Birth

Relationship to Patient

Assignment Authorization / Office Fee Policy: I hereby authorize Loredo Hand Care Institute to release to my insurance company any information including the diagnosis and records of any treatment or examination rendered to me. I authorize and request my insurance company to pay directly to the doctor the amount due for my pending claim. The parent/guardian accompanying the child for treatment will be responsible for all bills. Payment of any deductible, coinsurance, and/or co-payment is required at the time of service.

Signature *

Sign here

Relationship to Patient

Date

Medical History

Please provide your health history and current medications.

Basic Health Information

Height

Weight

Drug Allergies

Do You Drink Alcohol?

No Occasionally Regularly

Do You Smoke?

No Yes Former

Use Recreational Drugs?

No Yes

If So, How Much / How Often?

Past Surgical History

Please list all procedures and approximate dates

1.

2.

3.

4.

5.

6.

Any Problems with Anesthesia?

Current Medications

List all prescription and over-the-counter medications

1.

2.

3.

4.

5.

6.

7.

8.

Do You Take Blood Thinners, Vitamin E, Fish Oil, Phentermine, Aspirin, or GLP-1 Medications (Ozempic, Wegovy, Mounjaro, Zepbound, Trulicity)?

GLP-1 medications slow stomach emptying and must be disclosed before any procedure involving anesthesia or sedation. Please list the medication and your last dose.

Review of Systems

Please answer Yes or No for each symptom.

General

Symptom	Yes	No
Changes in weight
Progressive/Prolonged Fatigue

Pulmonary

Cardiac

Symptom	Yes	No
Wake up short of breath
Leg / Ankle swelling
Sleep okay
Palpitations / Heart flutters
Abnormal sensation with exertion (chest, arms, neck, back)

Infectious Disease

Gynecologic / Urologic

Psychiatric

Blood / Lymph

Head and Neck

Symptom	Yes	No
Decrease in hearing
Ringing in the ears
New Headaches
Sinus Problems
Sore throat
Changes in voice
Dry mouth
Sensory changes
TMJ / Jaw Pain

Eyes

Gastrointestinal

Symptom	Yes	No
Frequent Nausea / Vomiting
Abdominal pain

Skin

Neurological

Symptom	Yes	No
Dizziness
Difficulty walking

Musculoskeletal

Acknowledgement: To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform Loredo Hand Care Institute of any changes in my medical status. I also authorize the health care staff to perform the necessary services I may need.

Patient Name *

Date

Patient Signature *

Sign here

Hand & Elbow History

Tell us about your hand and arm concerns.

Have You Had an EMG / Nerve Study Done in the Past?

If So, Where Was It Done?

Insurance Acknowledgment, HIPAA & Endorsements

Please read and acknowledge each section below.

Acknowledgments

Notice of Privacy Practices: I acknowledge that I was provided a copy of the Notice of Privacy Practices (NPP), and that I have read and understand the NPP and agree to its terms. To file a complaint with the Texas Medical Board call 1-800-201-9353. Records Release: I hereby authorize Loredo Hand Care Institute to furnish any medical records and/or other necessary information needed to process an insurance claim. Assignment of Benefits: I am the financially responsible party and agree to pay in full for services rendered. I accept Loredo Hand Care Institute's fees as reasonable and customary. Should my insurance deny payment, I am responsible for the amount billed. Workers' Comp Declaration: I understand it is my responsibility to notify the office if I file a work comp claim. If my workers' comp claim is denied, I will be responsible for all balances in full. X-Ray & Ultrasound: I authorize Loredo Hand Care Institute to take x-rays and perform an ultrasound for my condition. I understand this information will be used to assist my doctor in the evaluation and treatment plan.

Patient Name *

Date of Birth

Signature of Responsible Party *

Sign here

Date

Ownership & Referral Disclosure

Texas law requires this disclosure. Please read carefully and acknowledge.

Texas law requires a physician to disclose to a patient those arrangements whereby the physician accepts remuneration to secure or solicit a patient or patronage for a person licensed by a Texas health care regulatory agency. Your attending physician(s) may receive remuneration for referring you to healthcare providers for certain services.

A physician must notify a patient that the physician has a direct financial interest in a diagnostic or treatment agency to which the patient is being referred, and whether these services are available elsewhere on a competitive basis. Patients are given a list of effective alternative resources and are assured they will not be treated differently by the physician if they choose an alternative provider.

Out of Network Referral Consent

I have the choice of using a participating health care facility/provider. If I choose to use a doctor or facility outside my network, my health insurance may not cover the services. By using out-of-network benefits, I may have higher out-of-pocket costs.

Physician Disclosure of Financial Interest

☑ The physician may have a direct financial interest in the diagnostic or treatment agency or in non-routine goods or services ordered for you.
☑ The physician may have a financial interest in the health care professional or facility where surgery is performed.

Patient Acknowledgment

I have the choice to use a health care provider in which my physician does not have an ownership interest. I wish to utilize a health care provider in which my physician has an ownership/investment interest, as described in this disclosure form. My physician's disclosures and involvement with surgery centers and other investments were explained to me. All my questions and concerns were addressed. I was given choices and I want to move forward with planned treatments.

Patient Printed Name *

Date of Birth

Patient Signature *

Sign here

Date

Physician-Patient Agreement

Please read and agree to the terms of care.

Loredo Hand Care would like to provide you with comprehensive health care. This care will include scheduled visits, medications as prescribed, consultations with other care providers, and diagnostic/treatment procedures as ordered.

I Agree To:

Notify the clinic at least one (1) day before missing any scheduled visit. Cancellations with less than 24-hour notice and no-shows are subject to a $25.00 fee not covered by insurance. Participate in the evaluation and treatment plans as agreed to with Loredo Hand Care. Give my consent for Dr. Pedro J. Loredo III, MD, and his clinical staff to perform medically necessary in-office procedures within the scope of my treatment and care, including but not limited to: application and removal of casts; application and removal of splints and orthoses; application, changing, and removal of dressings and bandages; suture and staple removal; wound care and debridement; aspiration and steroid (cortisone) injections for diagnostic or therapeutic purposes; trigger point and joint injections; closed manipulation and reduction of finger joints, dislocations, and fractures; manipulation and reduction of fractures under fluoroscopic (X-ray) guidance; procedures performed under ultrasound guidance; diagnostic imaging including X-ray, fluoroscopy, and ultrasound; and any other procedure reasonably indicated within the scope of my evaluation, treatment, and care. Inform Loredo Hand Care about all health care and medications I receive from other sources. I will not obtain pain medications from any other physician and will not change pharmacies without prior consent. Violation will result in immediate discharge. My family and I will treat the staff of Loredo Hand Care with respect, refraining from loud, abusive, or threatening language or behavior in the office or on the phone. I understand that Loredo Hand Care cannot safely provide routine medical care if I fail to comply with any component of this agreement. Failure to comply may result in termination of regular medical care or medications.

Notice Regarding AI in Patient Care: Texas law enacted during the 2025 legislative session requires physicians to clearly disclose when artificial intelligence (AI) is used in patient care, including for clinical decision support, documentation, or diagnostic assistance. Any use of AI is intended to support—not replace—the physician's professional judgment. All AI-related activities are conducted in full compliance with HIPAA. Patients retain the right to ask questions about how AI may be used in their care at any time.

Patient Name *

Date of Birth

Patient Signature *

Sign here

Date

Consent for Artificial Intelligence Use in Patient Care

Texas Medical Board disclosure. Please read and acknowledge.

Loredo Hand Care Institute uses artificial intelligence (AI) technology as part of its clinical and business operations. Texas law enacted during the 2025 legislative session requires physicians to clearly disclose when artificial intelligence is used in patient care, including for clinical decision support, clinical documentation, diagnostic assistance, imaging interpretation support, scheduling, communication, billing, and other administrative and business functions.

Any use of AI is intended to support — not replace — the professional judgment of Dr. Pedro J. Loredo III, MD. All clinical decisions remain the responsibility of your physician. All AI-related activities are conducted in compliance with HIPAA and applicable privacy law, and your protected health information is handled under the same safeguards described in our Notice of Privacy Practices.

You retain the right to ask questions at any time about how AI may be used in your care, and to speak with your physician about any concerns.

Patient Acknowledgment

I acknowledge that I have been informed that artificial intelligence may be used in my care and in the operations of this practice. I understand that AI is used to assist, and does not replace, my physician's professional medical judgment. I consent to the use of artificial intelligence as described above in my evaluation, treatment, care, and related business operations.

Patient Printed Name *

Date of Birth

Patient Signature *

Sign here

Date

Consent to Electronic Signature and Electronic Records

Please read and acknowledge before submitting your forms.

By completing and submitting these forms electronically, you are signing them with an electronic signature. Under the federal Electronic Signatures in Global and National Commerce Act (E-SIGN, 15 U.S.C. § 7001 et seq.) and the Texas Uniform Electronic Transactions Act (Texas Business & Commerce Code Chapter 322), an electronic signature has the same legal force and effect as a handwritten signature, and an electronic record has the same legal validity as a paper record.

Your signature is captured electronically, encrypted in your web browser before it is transmitted, and stored as part of your medical record. Loredo Hand Care Institute may rely on these electronically signed documents to the same extent as originals signed in ink. You may request a paper copy of any document you sign, and you may withdraw consent to electronic signature by contacting the office at (972) 939-4974 before submitting these forms.

Patient Acknowledgment

I agree that my electronic signature is the legal equivalent of my handwritten signature and is binding. I agree that these electronically signed documents and electronic records are valid, enforceable, and may be relied upon by Loredo Hand Care Institute. I confirm that I have read, understood, and agree to each document I have signed in this intake packet.

Patient Printed Name *

Date of Birth

Patient Signature *

Sign here

Date

HIPAA Release Form

Authorize who may receive your medical information and your messaging preferences.

Patient Information

Patient Name *

Date of Birth

Release of Information

I authorize the release of information including the diagnosis, records, examination rendered to me, and claim information to the following persons:

Name 1

Relationship

Name 2

Relationship

Name 3

Relationship

Name 4

Relationship

Message Preferences

Please call me at:

Home

Work

Cell

If Unable to Reach Me:

You may leave a detailed message Please leave a message asking me to return your call Do not leave a message

Signature

Signature *

Sign here

Date

Symptom	Yes	No
Cough
Shortness of breath
Wheeze
Snoring

Symptom	Yes	No
Suicidal thoughts
Hallucinations
Memory loss
Feeling depressed / anxious

Symptom	Yes	No
Blurred vision
Eye pain
Redness
Watering
Light sensitive
Dry feeling

Treatment	Yes	No	Did This Help? / Describe
Anti-Inflammatory / Pain Medications
Splints
Cortisone Injections
Physical Therapy
Chiropractic
Surgery
Other

Symptom	Yes	No
Fever
Night Sweats
Recent Infection

Symptom	Yes	No
Incontinence
Difficulty / Painful urination
Blood in urine

Symptom	Yes	No
Easy bruising
Frequent nose bleeds
Swollen glands

Symptom	Yes	No
Changing moles
New rash
Tendency to form Keloid

Demographics

Medical History

Review of Systems

Hand & Elbow History

Insurance Acknowledgment, HIPAA & Endorsements

Ownership & Referral Disclosure

Physician-Patient Agreement

Consent for Artificial Intelligence Use in Patient Care

Consent to Electronic Signature and Electronic Records

HIPAA Release Form

Forms Submitted Successfully