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Patient Information

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Monday to Friday

8AM to 4PM

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Lone Star Orthopaedics
Dr. James A. Amis
Dr. Robert A. Raines

It is our goal to give you the best possible medical care. To do so, it is important that we keep your patient information accurate.

Please enter your information in the form below.

Your information will be submitted directly to our office.

Your Information

First Name:

Last Name:

Middle Initial:

Address:

City:

State:

Phone:

Birth Date:

Sex:

Married:

Employer:

Occupation:

Work Phone:

Alternate Phone:

Primary Insurance Information

Primary Insurance:

Subscriber's Name:

Relationship:

Employer:

Insurance Number:

Subscriber's Date of Birth:

Secondary Insurance Information

Secondary Insurance:

Subscriber's Name:

Relationship:

Employer:

Insurance Number:

Subscriber's Date of Birth:

Workers' Compensation Injury

Date of Injury:

Employer:

Phone:

Email:

Contact:

INS/MCO:

Claim Number:

Contact:

Injury Site:

Spouse or Minor's Parent Information

First Name:

Last Name:

Relationship:

Address:

City:

State:

Zip Code:

Employer:

Work Phone:

Alternate Phone:

Referral Information

Referred by:

City:

State:

Zip Code:

Primary Care Physician:

Pharmacy Information

Pharmacy:

Alternate Pharmacy:

Emergency Contact Information

First Name:

Last Name:

Relationship:

Address:

City:

State:

Zip Code:

Contact's Phone:

Alternate Phone:

Comments:

Office Info

Patient Information

Driving Directions

Patient Forms

ARE YOU A GOOD PATIENT?

AETNA PATIENTS

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