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New Location!!!
4137 South Sherwood Forest Blvd.,  Suite 110
Near Coursey
(225) 291-2626
info@spinesmith.com 

New Patient Information Forms

I hope that visiting this website has been the beginning of a positive experience for you at our office.


We want your first visit to our office to be as easy and efficient as possible. One of the ways we get to know about you and your health, as well as to better communicate with your primary physician and insurance company is from information that you provide on paper.

To this end, the following forms may be downloaded and completed at your convenience before your appointment. We will add them to the information the doctor will review on your first visit. Doing this ahead of time will decrease the time you spend completing paperwork,
so more time can be spent with the doctor.

1. Please select the forms package that best describes your situation:

  • New Patient Introduction Form for all patients.  ( Only file out the worker injury or Auto Accident forms if needed)  Or
  • NOTE:  If you contact our office you can log into our patient Kiosk and enter this information directly into your patient records to save time !) 
     ASH,  on behalf of Cigna,  requires completion of this additional  form.

     UnitedHealthCare requires additional forms to be completed by the patient. 

     For a neck complaint, complete the Patient Summary and the Neck Index

     For a back complaint, complete the Patient SummaryBack Index and Lower  Extremity Functional Scale

     For an Arm, Shoulder and Hand complaint, complete the Patient Summary,      Neck Index and DASH

 

 


2. To help us evaluate your progress, please select the correct set of questionnaires below which will provide us your baseline level of pain and function loss.

Experiencing neck pain? Please download and complete the following formNeck Disability Index (Vernon-Meyer)

Experiencing low back pain? Please download and complete the following form Low Back Disability Index (Oswestry)

If you should have any questions about these forms, please feel free to contact our office by telephone at (225) 291.2626 or by email  info at spinesmith.com.

If you have questions concerning your insurance plan and whether we are providers for that plan, please contact our office at (225) 291.2626 visit our Insurance Information page.




Back to home page. 

New Location!!!
4137 South Sherwood Forest Blvd., Suite 110
Near Coursey
(225) 291-2626
info@spinesmith.com 

Robert W. Smith, DC, DABCI

Visit our website!