Send Us Your MRIs & X-Rays for a Consultation with Dr. Stone

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Explore All Your Options! Receive a complimentary evaluation from a world-renowned orthopaedic surgeon by completing the form below in full.

Please note that this form is specifically for International Patients. If you live in the USA or Canada, please head here to arrange a consultation

Able to Travel to San Francisco? This consultation service is reserved for patients seeking future treatment with The Stone Clinic. Are you willing and able to travel to San Francisco, CA, USA for our care?
*

Yes

Are you experiencing an injury that requires urgent care? (Examples: Achilles injury, clavicle fracture, joint dislocation, or any traumatic injury causing severe pain)

Yes. If you are experiencing an urgent injury, please STOP filling out this form and call our office right away. We have live assistance available 24 hours a day, 7 days a week that can help expedite your care +1(415) 563-3110

Have you ever previously been a patient of The Stone Clinic?
*

Yes. If you are a Stone Clinic patient, we already have all info we need to start you care right away. Please STOP filling out this form and call our office at +1 (415) 563-3110 to get your care started. We have live assistance available 24 hours a day, 7 days a week.

Imaging Requirements for a Consultation

In order to deliver a consultation, we require medical imaging (MRI & x-rays) of the injured joint. Please collect all operative photos, operative reports, typed radiology reports, MRIs, and x-rays for the affected joint. The imaging must be completed within one year. All images must be postoperative, meaning after any previous surgeries.

Please do not send any viewing links/webpages from your imaging facility/radiologist as it will delay or prevent your consultation.

I have medical imaging that is less than 12 months old and will submit my imaging ONLINE.

I have medical imaging that is less than 12 months old and I will MAIL my imaging to The Stone Clinic

I do not have recent medical imaging. Please send me a prescription for MRIs & x-rays.

Please confirm the injury that you'd like to talk about during your consultation
*

Left Ankle

Right Ankle

Left Knee

Right Knee

Left Shoulder

Right Shoulder

Required

Patient First Name *

Please your write your legal first name & middle initial

Patient Last Name *

Please your write your legal last name

Date of Birth *

YYYY

Provide your preferred phone number. Please be sure to include your country code.
*

Please be sure to enter your phone number accurately as we may need to contact you via a phone call to coordinate your consultation.

Provide your preferred email address for communication with The Stone Clinic staff *

Please be sure to enter your email address accurately as this will be your primary form of communication with our Clinic team

AUTHORIZATION TO EMAIL PROTECTED HEALTH INFORMATION Part 1
Sensitive health information can be sent by email between The Stone Clinic and our patients if this form is completed and signed, To receive a consultation you must authorize this form of communication, by clicking the box below:
*

I authorize The Stone Clinic to email me regarding the course of my medical care, treatment, diagnostic test results, and all other types of protected health information.

Required

AUTHORIZATION TO EMAIL PROTECTED HEALTH INFORMATION Part 2

I understand that any email transmission between my provider and me/the patient will become part of my medical record. These email transmissions may be disclosed in accordance with future authorizations. I understand that I have the right to revoke this Authorization at any time. If I want to revoke this authorization, I must do so in writing and address it to the entity that I had previously authorized to disclose my information. I understand that if I revoke this Authorization, it will not apply to any information already released as a result of this authorization. I understand that this Authorization is voluntary and that I may refuse to sign it. I understand that, once information is disclosed pursuant to this Authorization, it is possible that it could be disclosed by the entity that receives it for authorized purposes under the HIPAA privacy rule.

Alert for Electronic Communication

Patients and/or personal representatives who want to communicate with their health care providers by email should consider all of the following issues before signing an Authorization to Email Protected Health Information:

1. Email communications can be forwarded, intercepted, printed and stored by others.
2. Email communication is a convenience and is not appropriate for emergencies or time-sensitive issues.
3. Highly sensitive or personal information should only be communicated by email at the patient’s discretion (i.e., HIV status, mental illness, chemical dependency, etc.).
4. Employers generally have the right to access any email received or sent by a person at work.
5. Staff other than the health care provider may read and process email.
6. Clinically relevant messages and responses will be documented in the medical record at the provider’s discretion.
7. Email message content must include (1) the subject of the message in the subject line (i.e., appointment request, medical records request, etc.) and (2) clear patient identification including patient name, telephone number, and date of birth in the body of the message.
8. The Stone Clinic will not be liable for information lost or misdirected due to technical errors or other failures.
9. The Stone Clinic will take reasonable measures as outlined by HIPAA to protect patient information, but will not be liable for information that is viewed or otherwise accessed by unauthorized parties for email messages sent or received through unencrypted third party email providers such as Gmail, Yahoo, Hotmail, Microsoft Outlook, and other such carriers.

I have read and understand the Alert for Electronic Communications and authorize The Stone Clinic to communicate with me via email, including messages that may include protected health information about me / the patient, whenever necessary. This Authorization will not expire unless revoked in writing.

Required

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms