Special Spine Institute: Forms - Physician Referral

Complete this form to begin the patient referral process. A representative in your office will be contacted by one of our Referral Specialists to collect additional information. The patient will be contacted and the appointment confirmed.

Information about the Referring Physician

First Name

Street Address

State

Country

Physician's E-mail (required)

Last Name

City

Zip

Office Phone

Office Fax

Information about the Patient

* First Name

Last Name

Street Address

State

Country

City

Zip

Gender : Male Female

Age : (years)

SSN (XXX-XX-XXXX)

Date of Birth (MM/DD/YYYY)

Day Phone

Evening Phone

Cell Phone

Email

* Patient Diagnosis Information

Please tell us about your problem : Walking Sitting Standing Sleeping Driving	Working Balance Other Symptoms? How did this problem begin? What Happened?
Please Rate (0= no pain, 10=worst pain) Low Back Pain : Right Leg Pain : Right Leg Weakness : Right Leg Numbness : Left Leg Pain : left Leg Weakness : Left Leg Numbness : Neck Pain : Right Arm Pain : Right Arm Weakness : Right Arm Numbness : Left Arm Pain : left Arm Weakness : Left Arm Numbness :
Bowel Function : if not normal, please describe : Bladder Function : if not normal, please describe : (If not normal PLEASE SPEAK TO YOUR MEDICAL DOCTOR OR EMERGENCY ROOM IMMEDIATELY)
Last Visit to : Neurologist Name : Last Visit Date : Orthopaedist : Last Visit Date : Please describe your studies – include dates and results
X-ray	Myelogram
CT	MRI
other
Insurance Coverage :	No Fault Coverage :
Worker’s Compensation Coverage :

Referral Information

Are you referring to a specific physician? Yes No

Physician Name

One of our Referral Specialists will call your office to discuss this referral further and to obtain additional information pertinent to this patient. Please indicate the contact person who can best assist with this referral.

First Name Last Name

Contact Title Daytime Phone and Extension

Your patient will also be contacted in order to review insurance coverage and obtain additional demographic information. Medical and financial eligibility will need to be established prior to confirming an appointment. If you would like to leave a message for the Office, please type it here.

All E-Mail Referral Forms will receive a response within 48 hours excluding weekends and holidays. The Office is open Monday through Friday from 8:00 a.m. to 5:00 p.m. EST (1-845-471-9200).