Thank you for your interest in our services -- please fill out the New Patient Application form below before your first appointment.
Read this first...
NAVIGATION - do not use the "BACK" button on your browser to go back to a prior page - instead use only the buttons provided at the bottom of each page to navigate. Using the "BACK" button will take you to a prior webpage and close out the form.
AUTO-SAVE DELAYS - this form auto-saves all data entered every 30 seconds to avoid data loss and re-work. However, this means that your may encounter a slight delay every 30 seconds as you fill out the form - a small price to pay for avoiding double work in case you accidentally close your browser.
HIPAA COMPLIANCE - we use SSL encryption on these forms and safeguard your information. If you are concerned about answering any question, just leave those fields blank and we will collect that information in our office. Alternatively, you can download a PDF form to fill out offline at this link.
MEDICARE PATIENTS - If you are a Medicare patient, then please contact us by telephone at 602-298-1600 for special instructions before proceeding.
This form will require approximately 20 minutes to complete.
Please wait for the SpinalWorks logo to appear at the top of this page before proceeding...
- Dr. VanLaecken