Monthly Archives

May07

Pediatric Patient Registration

PEDIATRIC PATIENT REGISTRATION

Child's Name *

Date of Birth *

Height *

Weight *

Address *

Country

City

State

Zip code

Sex *

Male

Female

Primary Phone Number *

Is this a cell # *

Yes

Cell/Work Phone *

Email *

Referring Physician name *

Referring Physician Phone *

Do you have a script from your physician? Upload here.

Primary Policy Insurance Name *

Member ID *

Subscriber Name *

Subscriber Date of Birth *

Secondary Insurance Information

Member ID

Subscriber Name *

Subscriber Date of Birth

Person(s) authorized to discuss your child's personal healthcare information

Name

Relationship

Name

Relationship

ADDITIONAL CONTACT QUESTIONS:

Who should be receiving billing statements? *

IF PARENTS ARE DIVORCED OR SEPARATED PLEASE FILL OUT THIS SECTION

Who has custody?

Are there any legal restrictions that would restrict the non-custodial parent from consenting to medical treatment for the child or from obtaining information about the child's medical treatment?

Yes

If yes, please provide a copy of any legal paperwork that supports this restriction. Upload here.

Please Read and Consent for medical payments: *

I request that payment of authorized medical benefits be made, when this option is available by insurance carrier, on my behalf to Delatorre Orthotics & Prosthetics, Inc. for any services rendered by the supplier. I authorize any holder of medical information about my child to release to the Centers for Medicare & Medicaid Services (CMS) and its agents any information needed. I agree to pay deductibles, co-insurance and any amount not covered by my insurances. I also acknowledge that I have received the Notice of Pricacy and Consent regarding the use of my child's personal health information.

Yes, I consent

Please Read and Consent for Treatment of Minor Child *

I hereby authorize and request the designated clinicians of Delatorre O & P to provide the needed orthotic item.

Yes, I consent

Mar16

COVID-19

As the COVID-19 (Corona Virus) has expanded into Pennsylvania, De La Torre Orthotics & Prosthetics, Inc. is taking every precaution to assure your safety and the safety of our employees.

Our offices will be using EPA approved disinfection techniques throughout the day.

These precautions include:
Spraying and wiping all surfaces
Removal of all toys, magazines and printed notices
Care in disinfecting all pens before and after patient use
Consistent hand washing by all personnel per CDC (Center for Disease Control) guidelines

We are continuously monitoring and following all guidelines presented by the CDC and the Pennsylvania Department of Health as well as initiatives by the Pennsylvania Office of the Governor.

 OUR REQUEST TO YOU, OUR PATIENTS:

If you have an upcoming appointment scheduled with us and have a fever, cough and/or difficulty breathing, have traveled to or had close contact with someone who has traveled to high risk countries, or have tested positive for or been exposed to someone with COVID-19, we ask you to reschedule your appointment for a minimum of 2 weeks until you are cleared from being potentially positive from COVID-19.

If you have any questions about an appointment, please call us at any of our office locations or our prosthetics department (412-599-1105) or pediatric administrator (412-599-1117).

If you are interested in following the latest COVID-19 updates, you can do so on the CDC’s website or the PA Department of Health website https://www.health.pa.gov/topics/disease/Pages/Coronavirus.aspx

We appreciate your understanding of our desire to care for you and for our staff.

May10

Down Syndrome Center Podcast featuring Delatorre Orthotics and Prosthetics

Dec19

Mark Daniels – Royal Australian Navy

On this episode of revAMPd Brian talks with Royal Australian Navy Marine Technician, motivational speakers and right above knee amputee Mark Daniels about his incredible journey following a horrific accident in which doctors did not believe he would survive. Mark proves that with enough drive and determination anyone can overcome any challenge they face in life.

For more information about Mark, connect with him on Facebook @MarkDanielsMotivation

For more information about revAMPd visit www.revampdpodcast.com and connect with us on Facebook, twitter and Instagram @revAMPdPodcast

Dec11

Jenny Pollreis – PegLeg Trainer

On this episode of revAMPd Brian talks with Peg Leg Trainer and Rush Foot ReBELLE Jenny Pollreis.

Join Brian and he and Jenny discuss her inspirational journey, raising kids post amputation, and why hard work and dedication truly pays off.

For more information about Jenny visit www.peglegtrainer.com and connect with her on Facebook, twitter and Instagram.

In 14 years as an amputee, Jenny has tried almost every type of carbon foot available (and broken them). Now that she’s on a fiberglass foot, she isn’t shy about sharing her love for the RUSH ROGUE! Check out Jenny’s testimony about her experience with the Rush Rogue https://youtu.be/oPLffsVTBlk

For more information about revAMPd visit www.revampdpodcast.com and connect with us on Facebook, twitter and Instagram @revAMPdPodcast

Dec04

Josh Green

On this episode of revAMPd Brian talks with dad, coach, chef, patient advocate and recently engaged RAKA Josh Green.

Join Brian as he and Josh discuss Josh’s lifelong journey as an amputee, chef, coach patient model and his most important role, dad.

For more information about Josh, connect with him on Facebook @ChefJGreen

For more information about revAMPd visit www.revampdpodcast.com and connect with us on Facebook, twitter and Instagram @revAMPdPodcast

Nov26

Adrianne Haslet

On this episode of revAMPd Brian talks with a global advocate for amputee rights, keynote speaker, ballroom dancer, blade runner and Boston Marathon bombing survivor, Adrianne Haslet.

Join Brian as he and Adrianne discuss her inspirational journey, involvement in advocacy for the limb loss community and so much more.

For more information about Adrianne visit www.adriannehaslet.com and connect with her on Facebook, twitter and Instagram

Check out Adrianne in PBSM’s official video for “Dance Floor”

For more information about revAMPd visit www.revampdpodcast.com and connect with us on Facebook, twitter and Instagram @revAMPdPodcast

Nov20

Adaptive Strongman Mason Hall

On this episode of revAMPd Brian talks with bilateral amputee, adaptive athlete and the architect of the revAMPd podcast name, Mason Hall. Join Brian as he and Mason discuss Mason’s limb loss journey, adapting to the new normal and moving on with life.

For more information about Mason, connect with him on Facebook, Instagram and YouTube

For more information about revAMPd visit www.revampdpodcast.com and connect with us on Facebook, twitter and Instagram @revAMPdPodcast

Nov13

“The Roaming Rebel” Chris Bowman

On this episode of revAMPd Brian talks with life long transtibial amputee “The Roaming Rebel” Chris Bowman. Join Brian as he and Chris discuss Chris’ many adventures as well as his inspirational journey with limb loss.

For more information about Chris connect with him on Facebook, twitter and YouTube

For more information about revAMPd visit www.revampdpodcast.com and connect with us on Facebook, twitter and Instagram @revAMPdPodcast

Nov06

“The Raging Panda” Nick Koulchar

On this episode of revAMPd Brian talks with U.S. Army Veteran, Wounded Warrior, Adaptive Athlete and Keynote Speaker, “The Raging Panda” Nick Koulchar. Join Brian as he talks to Nick about his long road to recovery after losing both legs while defending the United States in Operation Iraqi Freedom, being adaptive, competing in marathons and crossfit as well as fatherhood and how to overcome any obstacle we face in life.

For more information about Nick visit www.andbeyondconsult.com and connect with him on Facebook, twitter and Instagram

For more information about revAMPd visit www.revampdpodcast.com and connect with us on Facebook, twitter and Instagram @revAMPdPodcast

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Monthly Archives

PEDIATRIC PATIENT REGISTRATION

ADDITIONAL CONTACT QUESTIONS:

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For our valued patients and healthcare colleagues:

We ask that all patients please come to our offices wearing a face mask.