Online Appointment Form

This form is not to be used in the case of an emergency. If this is an emergency, please call 911 or your local emergency services provider.

PRIVACY INFORMATION
In order for you to submit an online request for an appointment, you will need to provide confidential medical information. By proceeding through this notice and providing the requested demographic and medical information, you consent to the disclosure of such information to the relevant staff of SpineCare LLC.

The information you provide here will not be used for any other purpose than to schedule this appointment, and will not be shared with or sold to any other organizations, and tracers will not be used to collect information or track your computer use.

NOTICE OF PRIVACY PRACTICES
SpineCares's Notice of Privacy Practices may be accessed at this link. In order to complete your request, you must acknowledge receipt of this notice in the form below.

Appointment For:
Patient's Last Name:*
Patient's First Name:*
Patient's Middle Initial:
Street Address:*
City:
State:
Zip/Postal Code:
Country:
Date of Birth:
Day:*	Select Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Month:*	Select Month 1 2 3 4 5 6 7 8 9 10 11 12
Year:*	Select Year 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986
Where to Contact You:
Daytime Phone:*
Cell Phone:
E-mail:
Best time to contact you by phone?	Select from List 8am-11am CST 1pm-3pm CST 3pm-6pm CST
Appointment Information:
Type of Appointment:*	Select Type of Visit New Patient Follow Up Post Op Visit Second Opinion
Were you referred by a Physician?	Yes   No
Referring Physicians Name:*
Referring Physicians Address:*
Referring Physician City:*
Referring Physician Zip/Postal Code:*
Referring Physician Phone:*
Referring Physician Fax:
What Physician were you referred to?	Select from List Stanley C Jones MD Kenneth J.H. Lee MD
Referral Reason:	Select Reason for Referral from List Arthritis Back Pain Cerebral Palsy Do Not Know Hip Problems Other Spina Bifida Spinal Deformity Sports Injury
Location/site of injury:
Other related conditions: