Patient Forms

instructions3
 
PLEASE READ THE FOLLOWING INSTRUCTIONS BEFORE PROCEEDING TO THE FORMS BELOW. Follow instructions A for new patients and B for follow-up.

A1. Use this page to download "new patient" forms. All files are in Adobe Acrobat format. If you do not have the Adobe Acrobat reader, you can download it here


A2. If you are a new in-state patient, Dr. Gross prefers to evaluate you in the office to see if you are a candidate for surgery. Please schedule an initial office visit by calling us at (803) 256-4107. For new out-of-state patients (or those unable to come to our office), we will need ALL the materials from the new patient packet (see section I under new patient forms). PRINT, FILL OUT, AND MAIL IN. If you would like to have a telephone consultation with Dr. Gross or need help putting together your "new patient package", please contact Evelyn W at (803) 933-6170 or email at This email address is being protected from spambots. You need JavaScript enabled to view it..

Once complete, please FedEx the package to:

Thomas P. Gross M.D.
Midlands Orthopaedics & Neurosurgery, P.A.
1910 Blanding St.
Columbia, SC 29201

  
 
B1. Use this page to download "follow-up" forms. All files are in Adobe Acrobat format. If you do not have the Adobe Acrobat reader, you can download it here
 
B2. We request postoperative follow-up at 6 weeks (4 weeks for knees), 6 months, 1 year, 2 years, and every 2 years therafter. You can schedule an in-office visit for each of these intervals by calling (803) 256-4107, or you can complete a remote follow-up. For remote follow-ups, please download the follow-up package below AND READ THROUGH THE INSTRUCTIONS CAREFULLY. PRINT, FILL OUT, AND MAIL IN. We require the following materials for your remote follow-up:
 
  • 6 weeks (4 week knees) - questonnaire, physical exam, x-rays, and mission statement disclosure form
  • 6 months - questonnaire, physical exam, and x-rays
  • 1 year - questionnaire, physical exam, and x-rays
  • 2 year hips - questionnaire, x-rays, and metal ion test | 2 year knees - questionnaire, physical exam, and x-rays
  • >2 years - questionnaire and x-rays

 

 New Patient Forms

Please submit all initial evaluation materials (please review the packet in its entirety, using the first page as a checklist) before your first visit. All section II forms are required before scheduling your surgery. If you are a new patient and would like assistance with preparing or submitting your new patient package, please contact Evelyn W at (803) 933-6170 or email at This email address is being protected from spambots. You need JavaScript enabled to view it. .

OUT-OF-STATE PATIENTS: When all information is submitted, Evelyn will send the completed file to Dr. Gross for review. Usually, he will be able to call you within 3 weeks of receiving your information. Please be alert to calls from a blocked phone number or from any phone # with an 803 area code because Dr. Gross will call from home, the office, or the hospital.

I. For initial evaluation (choose one):
  1. New hip patient packet
  2. New knee patient packet
II. Information needed to schedule surgery (after initial eval):
  1. Mission Statement and Disclosure Form
  2. Please read our Privacy Information Form
  3. CBC Request (your PCP can order this)
  4. Please read through Insurance Information carefully
  5. *Optional/As needed* - Claimant Information for Disability/FMLA Benefits

*Section II forms (not necessary for intial evaluation) ARE REQUIRED PRIOR TO SCHEDULING SURGERY.

Follow-Ups

For a postoperative FOLLOW-UP evaluation, please click one of the following links, download the form and mail to us along with your x-rays. Dr. Gross will review your material, have his staff send confirmation to you via email, and he will personally contact you ONLY to notify you of any concerns or at your request. If you have difficulties with this, please call us at 803-933-6127 or email us at This email address is being protected from spambots. You need JavaScript enabled to view it. .

  1. Hip Follow-up Package
  2. Knee Follow-up Package

Patient Care Paths

  1. Total Hip Arthroplasty Care Path
  2. Total Knee Arthroplasty Care Path

Surgical Risk Disclosure

  1. Hip Resurfacing Consent Form
  2. Total Hip Arthroplasty
  3. Total Knee Arthroplasty

Others

  1. Hospital Discharge Instructions
  2. Phase I Hip Exercise
  3. Phase II Hip Exercises
  4. Psoas Stretching Testimonial
  5. Postoperative Knee Exercises
  6. Disability Form
  7. Medical Records Request Packet

Located in South Carolina

Irmo Office

1013 Lake Murray Blvd.
Irmo, SC 29063

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Columbia Office

1910 Blanding St.
Columbia, SC 29201

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