Welcome to our ONLINE CONSULTATION FORM.  Click the "Start button below to begin.
Start
 
Welcome and thank you for choosing Oklahoma Joint Reconstruction Institute.  We have created an online consultation to allow for easy and convenient review of your case in order to best advise you on your surgical and non-surgical options. You will be able to upload x-ray images and forms. Cell phone images of x-rays and forms are acceptable.

Sincerely,
Dr. Paul B. Jacob D.O.
Founder and CEO of Oklahoma Joint Reconstruction Institute
Board Certified and Fellowship Trained Hip and Knee Replacement Surgeon

 
What is your full legal name? *

As it appears on your medical records
 
What is your preferred contact phone number? *

 
How would you prefer that we contact you? *



 
What is your gender? *



 
What is your date of birth age AND age in years? *

Example: 1/1/1950 age 67
 
What is your body weight in pounds? *

Example: 180 lbs
 
What is your height in feet and inches? *

Example: 5 ft 10 in
 
Do you have a referral from a Physician? *

In most circumstances you do not need a referral from a physician to be seen.  PLEASE VERIFY WITH YOUR INSURANCE COMPANY if you are not sure.
     
 
What is the name of the Physician that referred you?

 
Have you seen another Orthopedic Surgeon for this Issue? *

     
 
Is this a second opinion? *

     
 
Give a short description of why you are seeking a second opinion.

Example:  I would like to see if I am eligible for robotic knee replacement......
 
What joint(s) are you having a problem with? *


 
What activities are painful? *


 
What is your pain level on a 0-10 scale AT ITS WORST? *

0 would be ABSOLUTELY no pain and 10 would be EMERGENCY ROOM pain
 
What improves your pain? *


 
What is your pain level on a 0-10 scale AT ITS BEST? *

0 would be ABSOLUTELY no pain and 10 would be EMERGENCY ROOM pain
 
What symptoms are you experiencing? *


 
How long have you had symptoms? *

 
How often does the pain occur? *


 
How would you describe the pain? *


 
What treatment(s) have you already tried? *

Please choose all that apply

 
Which Medications Have you tried? *


 
Do you have an allergy or sensitivity to metal?  *


 
What metal are you allergic to?


 
Describe your allergic reaction to metal. *

 
Would you like to be tested for metal sensitivity?

The amount is between $400.00 – $600.00 and insurance will NOT cover this in most circumstances.
     
 
Has the joint you are having trouble with already been partially or completely replaced?

     
 
Tell us about your previous surgical experience?

 
What was the previous surgery performed? *


 
Who Performed the previous surgery? *

Example: Dr. Smith
 
What hospital was the previous surgery performed at? *

Example: McBride Orthopedic Hospital
 
When was the previous surgery performed? *

Be as accurate as you can
 
How many times has the joint been operated on? *

 
Give a short description of your previous surgery. *

 
Please upload pictures of your previous xrays

A cell phone picture is acceptable. You may also mail your images or drop them off at my office at: 

Community Hospital North Campus
ANNT: Dr. Paul B. Jacob - Online Consultation 
9800 Broadway Ext Suite 201 
Oklahoma City, Oklahoma 73114
 
Upload Previous Medical Records

This may be obtained from your previous surgeon or the hospital where your surgery was performed.A cell phone picture is acceptable. You may also mail your images or drop them off at my office at: 

Community Hospital North Campus
ANNT: Dr. Paul B. Jacob - Online Consultation 
9800 Broadway Ext Suite 201 
Oklahoma City, Oklahoma 73114
 
What treatment(s) are you interested in finding out about? *

Please choose all that apply

 
What surgical treatments have you had? *


 
What hospital was the previous surgery performed at? *

Example: McBride Orthopedic Hospital
 
Leave a short description of the history of your problem. *

 
Upload your current x-rays

A cell phone picture is acceptable. You may also mail your images or drop them off at my office at: 

Community Hospital North Campus
ANNT: Dr. Paul B. Jacob - Online Consultation 
9800 Broadway Ext Suite 201
Oklahoma City, Oklahoma 73114
 
Upload Previous Medical Records

This may be obtained from your previous surgeon or the hospital where your surgery was performed.A cell phone picture is acceptable. You may also mail your images or drop them off at my office at: 

Community Hospital North Campus
ANNT: Dr. Paul B. Jacob - Online Consultation 
9800 Broadway Ext Suite 201 
Oklahoma City, Oklahoma 73114
 
Upload your previous operative report

This may be obtained from your previous surgeon or the hospital where your surgery was performed.A cell phone picture is acceptable. You may also mail your images or drop them off at my office at: 

Community Hospital North Campus
ANNT: Dr. Paul B. Jacob - Online Consultation 
9800 Broadway Ext Suite 201 
Oklahoma City, Oklahoma 73114
 
What treatment(s) are you interested in learning more about? *

Please choose all that apply

 
How did you hear about us? *


Thank you for choosing Dr. Paul B. Jacob and Oklahoma Joint Reconstruction Institute.  We have received your online consultation.  We will contact you after we have had a chance to review your case. to allow for easy and convenient review of your case. 

Sincerely,
Dr. Paul B. Jacob
Founder and CEO of Oklahoma Joint Rconstruction Institute
Board Certified and Fellowship Trained Hip and Knee Replacement Surgeon
Done
We’ve received your online consultation request.  Thank you for taking the time to answer our questions.  We will do out very best to get back to you in a timely manner.  Please do not hesitate to contact my office at (405) 424-5426 at any time for further assistance.
again