Choose One
Date and Time of Appointment*
:  

If you are unable to keep this appointment, please provide 24 hour notice.

If you are scheduled for a PROCEDURE (INJECTION),

 

  • Please remember that you will need a driver after the procedure.
  • If you are on any type of blood thinner, please consult with our clinical staff to determine if you are required to discontinue those medications a week before your procedure or if a test will be required prior to the day of your procedure to determine if the procedure can be performed.
  • If your procedure involves a cervical injection (involving the neck), please do not eat or drink anything at least six (6) hours prior to the procedure. If your procedure involves the lumbar spine (involving the back) you do NOT have to fast prior to the procedure.

If you have ANY change in your insurance prior to your appointment please notify our office before the day of your appointment. Many insurance contracts require prior authorizations and/or referrals. Appointments will be rescheduled until we can verify that appropriate authorizations and/or referrals have been obtained. Failure to provide current insurance information will result in the transfer of financial responsibility to you if the insurance denies payment based on lack of authorization or referral due to failure to report changes in your coverage.

Name*
Use your mouse or finger to draw your signature above
Today's Date*