Innovative Physiatry Spine Clinic

Forms


Forms

Thank you for choosing Innovative Physiatry Spine Clinic for your healthcare needs. To schedule an appointment, please call our office at (904) 671-0288. Upon scheduling your appointment, please download, print and complete the new patient registration forms.

For new patients, please plan to arrive 30 minutes earlier to provide the completed forms and the following items:

1. Valid Identification issued by the United States Federal or State Government. I.e Driving license

2. Insurance card(s)
  • 3. Referral letter
    4. Any MRI, CT, and X-Ray reports
    5. Completed new patient
    6. Registration forms

New Patient Paperwork.

Please download this document and complete it before you come in for your appointment.

Patient Health Questionnaire (PHQ).

Please download this document and complete it before you come in for your appointment.

Opioid Risk Tool (ORT).

Please download this document and complete it before you come in for your appointment.

Current Opioid Misuse Measure (COMM).

Please download this document and complete it before you come in for your appointment.

Please find the rest of the forms that you may need. Please download and complete them. Thanks

Medical Release Form.

Please use this form if you need to update the document. The validity is usually one year.

Referral Form - Health Insurance.

This form is intended for providers to submit referrals to our office. Please fax the completed referral, along with any necessary medical records and imaging reports, to (904) 508-0674. We greatly appreciate your referral!

Referral Form - Automobile Accident.

This form is intended for providers to submit referrals to our office. Please fax the completed referral, along with any necessary medical records and imaging reports, to (904) 508-0674. We greatly appreciate your referral!