Dr. Mikulak Forms

Download, Print, and Complete These Forms Prior To Your First Visit…

1) Patient Information Form

2) Medical Information Release Form (HIPAA)

3) Patient Financial Agreement

4) Initial Visit History – Lower Extremity

4) Initial Visit History – Upper Extremity

5) Patient/Physician Contract

6) No Show Policy

Remember to bring the following items:

• X-ray, MRI, EMG or other studies
• Operative reports
• Diagnostic test results
• Insurance information
• Current list of medications
• Photo identification