Align Clinic, LLC

Scoliosis Patient Update

For brace received on:

Date of Birth :

For girls: has the patient started her menses?
YesNo

If so, when?

For boys: has voice changed? :

YesNo

If so, when?

Date of last X-ray :

Date of LAST appointment with prescribing doctor :

Date of NEXT appointment with prescribing doctor :

Brace wear time (hours/day) :

Note: It is critical to closely monitor the patient at 9, 12, and 15 months of wear so the brace is not too short for the patient. A short brace can have negative effects.

I hereby give Align Clinic, LLC consent to obtain and release information and to photograph my child’s image to be used in the following ways:

• Communicate with other scoliosis professionals (ie: Dr. Rigo, Schroth PTs, referring physician/staff, and others)

• Submit to insurance companies to meet coverage criteria.

Date of Signature :

Sign here ( use the mouse or your finger on mobiles or tablets ) :

This form must be sent to:
—Please choose an option—San Mateo - CA (Jolene Freeman)Green Bay - WI (Lynn Chervenka or Marsha Holtzheimer)The Woodlands - TX (Norma Prieto)Lauderdale - FL (Lynn Chervenka or Marsha Holtzheimer)Boulder - CO (Stephanie Romero)

Please check that all information is completed and try to submit the form until you receive a successfully sent message, thanks.