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- Full name
- Date of Birth
- Home/Work phone numbers
- Which body part needs evaluation?
- Is your injury work related?
- Referring physician name and phone number
- Insurance information/name of your carrier
- Old or new injury?
- Have you seen a physician for this injury in the past?
- Do you have any x-ray or MRI films?
What to Bring to Your Appointment
- Current health insurance card
- Referral from primary care physician (if applicable)
- Any appropriate medical records, x-rays, scans or MRI’s
- Worker’s Compensation or third party liability insurance company’s information including: insurance company name, address, claim number, adjustor’s name and phone number (if applicable)
- If patient is a minor (18 years or younger), a parent or guardian must accompany the patient to their appointment, or the patient must have written consent from a parent or guardian in order to be seen by a physician.
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