Innovative Physiatry Spine Clinic

(904) 671-0288

Potential Patient

  • Potential Patient

Questionaire For Potential New Patient Information

Thank you for choosing Innovative Physiatry Spine Clinic, where we prioritize putting the “Patient First.” 

Please provide the following information so that we can assess your needs and determine if our clinic is the right fit for you. 

We appreciate your time and look forward to serving you.

    First and Last name:
    Telephone number:
    Email address:
    Gender:
    Enter your Date of Birth
    How do you find out about us?
    Please let us the person who referred you:
    What is your health insurance? If you have a HMO plan, you will need a referral from your primary care doctor.
    If you choose other, please provide more information
    What is your health insurance ID?
    What is the co-pay amount printed on the card?
    What is your main concern?
    If other, please describe:
    Is your pain due to:
    Are you currently taking any type of pain medication? [radio* radio-pill use_label_element "Yes" "No"] If yes, what kind? Please indicate the name and dosage [/textarea] Are you currently under the care of a pain management doctor? [radio* radio-paind use_label_element "Yes" "No"] If yes, who is the doctor?
    Do you have any imaging done previously? [radio* radio-imaging use_label_element "Yes" "No"] If yes, when?
    If yes, where?
    Please attach a copy of the report (PDF only):
    For any other attachment, please send us an email to info@ipsclinic.net