New Patient Information

Thank you for choosing our practice for your care. The staff at Florence Neurosurgery & Spine would like to make your experience with our office at pleasurable one.

In order to better serve you, we ask our patients to bring the completed form below, their current insurance cards and driver’s license or other picture identification. Some of our physicians require that you bring the actual x-rays and/or other films with you before they able to see you. If you have any questions regarding this matter, please call before your appointment.


Patient Forms

If you are a new patient to our clinic, you may save time by completing the New Patient Forms prior to arriving for your appointment.

  • Patient Information
  • Patient Health History Questionnaire
  • Description of Problems
  • Back Pain & Leg Pain Questionnaire
  • Consent for Purposes of Treatment, Payment and Healthcare Operations
  • Patient Record of Disclosures 
  • Accident Questionnaire

Download the New Patient Forms


 

For patients with HMO’s or PPO insurances that require referrals, we must have an insurance referral from your primary care physician before you can be seen by our physicians.

If you were injured at work, we require a letter of authorization from your workman’s compensation carrier which includes the carrier name, address, phone number. This should also include the name and phone number of a contact person/claims adjuster. This information can also be mailed or faxed to our office prior to your visit.

We do not file automobile insurance or accept letter of protection from attorneys. If you do not have health insurance, please contact our office prior to your visit to discuss payment arrangements.

Our office requires payment for services rendered before leaving our office. Please bring any copay or deductibles that your insurance requires with you to your visit. If you are uninsured, please contact our office to discuss our payment policies and arrangements BEFORE your visit. Monthly payment arrangements may be offered to insure that your account is not sent to an outside collection agency or attorney.

As a courtesy to you, our office accepts cash, personal checks, money orders, Visa and Mastercard.

If you have any questions regarding your appointment or our office policy, please feel free to contact our office.