Patient Forms

Once you have made your initial orthopedic appointment it is time to provide us with an accurate medical history.

To ensure we have your accurate medical history available at your initial orthopedic appointment you can either:

1. Print and Complete Clinic Forms 1-5 below prior to your visit, OR
2. Please bring all necessary information with you to accurately complete all your medical and surgical history, and an updated list of all your medications, OR use your online patient portal to update medications prior to your appointment.

Established patients can update forms online through our patient portal or print and complete Form # 2 below. If you need help setting up or accessing the patient portal, please call our office at (406)721-4436 ext. 5937 and we’ll be happy to help.

If you are scheduled for physical therapy, surgery, or an MRI, please complete the appropriate forms below and bring them with you to your appointment.

Orthopedic Clinic Forms

1. Patient Registration Form
2. New Patient Health History Intake Form  OR Established Patient Intake Form
3. Patient Financial Policy
4. Notice of Privacy Practices
5. Notice of Privacy Practices Acknowledgement Form
6. MBJ Release of Information
7. Consent to Treat Minors Form
8. Surrounding Area MRI and X-ray Facilities

For New patients scheduled with Dr. Mark Channer and Alex Ramsey, PA-C: Please complete the Dr. Channer New Patient Intake Form

For New patients scheduled for a neck or back evaluation with Dr. Zackery Witte, Dr. Lindsey Beck, Joan, or Amie: Please complete the New Patient Neck and Back Form

Physical Therapy Forms

• Patient Contract / Financial Policy
• Physical Therapy Health History Form
• Consent to Treat Form
• Medicare Cap Form 2023

Surgery Center Forms

Patient Financial Policy for Ambulatory Surgery Center

Patient Instruction Sheet - before surgery, day of surgery, after surgery and at home.

Before Surgery: You will be asked to fill out Pre-Surgery forms with the Orthopedic Assistant for your Provider at your clinic visit prior to your surgery.

MRI Forms

Your answers to the questions on the MRI Metal Screening (page 2) will help us determine whether an MRI examination is safe for you based on your history. In addition, we need to determine whether there are any factors that may interfere with your study or may cause difficulty with the scan results.

The Federal Government (Patient Protection and Affordable Healthcare Act, Sections 6409 and 6003 dated March 23, 2010) mandates we provide information on facilities other than those owned by our physicians. You have the right to choose your facility. If you would like to receive services at another facility we will be happy to provide you with a referral. Here is a list of facilities: Surrounding Area MRI and X-ray Facilities

Before Your MRI Appointment

To save time at your MRI appointment, please fill out this MRI Patient History Form, Print Out and Bring With You to your MRI appointment.

If your procedure involves the use of contrast dye, you will be asked to sign a consent form that gives permission to do the procedure. Read the form carefully and ask questions if something is not clear. Contrast Information