Request Appointment


We understand you are busy and that sometimes the most convenient way for you to schedule an appointment is to make a request online.  Please complete the form below and a member of our team will contact you to schedule your appointment.
PLEASE NOTE THAT SCHEDULING HOURS OCCUR BETWEEN 8:30AM-5:00PM MONDAY-FRIDAY. While we will do everything to call you back as soon as possible, high call volumes may prohibit our team from calling you back immediately.  Callbacks will occur in the order of emails received. 

Your Name (required)

Daytime Phone (required)

Your Email (required)

Have you ever been a patient of Nebraska Orthopaedic & Sports Medicine?
YesNo

Address

City

State

ZIP Code

Date of Birth

Orthopedic Problem
Please (briefly) describe your orthopedic problem:

Is this a New or Old injury?
OldNew

Have you seen another orthopaedic doctor for this current problem/injury?
YesNo

Have you had previous surgery on this body part?
YesNo

Have you had any recent X-rays or MRIs taken? (required)
YesNo

If you have had images taken, when and where?
Note: You may need to bring images in with you to your appointment.

Is this a Worker's Compensation or Liability Claim?
Note: If you answer yes, please note that unless your work comp or liability claim is approved prior to your visit, we will need to bill to your personal insurance. Please have this information available when the receptionist calls to schedule your appointment.
YesNo

Work Comp Claim Number

Work Comp Adjuster Name (first and last)

Work Comp Adjuster Phone Number

What is your current insurance type? (required)
Please note we do not accept all insurance products or HMO plans.

Preferred Physician (if you are an established patient, please select your treating physician)

If you are being referred to our clinic by another physician, please tell us that referring physician's name:

When is the best time to receive a call from us to schedule your appointment?

What is your appointment time preference?