handsurg.com :: Hand Surgery Specialists, Inc.

If this is a medical emergency, please call 911 immediately.

Thank you for choosing Hand Surgery Specialists for your outpatient appointment.

We will do our best to meet your scheduling needs, but due to the high volume of appointment requests, selected preferred times are intended to serve only as guidelines. Please note that this is an appointment request and a scheduler will call you on the same day as your appointment request or the following business day to confirm your appointment.

If you prefer to speak to us to schedule your appointment, please call us at 513 961-HAND (4263).

Patient Information

1. Are you a new patient? Select Yes No
2. First Name(required)
3. MI
4. Last Name(required)
5. Date of Birth (MM/DD/YYYY)
6. Gender Select Female Male
7. Mailing Address
8. Apartment
9. City
10. State Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
11. Zip Code
12. Daytime Phone Number(required)
13. Alternate Phone Number
14. E-mail Address
15. Retype E-Mail Address

Scheduling

1. Physician of Choice Select Dr. Stern Dr. McDonough Dr. Kiefhaber Dr. Fassler Dr. Sommerkamp Dr. Reilly Dr. Markiewitz Dr. Cross
2. Location of Choice Select OH - Anderson OH - Arrow Springs OH - Clifton / Mt. Auburn OH - Montgomery OH - University OH - West Chester OH - Western Hills IN - Dearborn County KY - Northern Kentucky
3. Appt. Preference - Time of Day
4. AM PM
5. Appt. Preference - Days of Week
6. Mon Tue Wed Thu Fri

Medical Information for New Patients

1. Type of Insurance
2. Pre-Certification Number (if required)
3. Do you have a physician's prescription (note) for this requested appointment? Select Yes No
4. Name of Ordering/Referring Physician
5. Reason for Appointment (e.g., injury, accident, routing, follow-up)
6. Date of Injury or Date of Problem Onset (MM/DD/YYYY)

Additional Comments / Special Requests

1. Enter Comments/Requests

 

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Please note, on the date of your visit you will need to bring the following:

1. Medical Records, Test, X-rays pertaining to the reason for your appointment.
2. Insurance cards
3. Identification
4. Referral (if applicable)