Patient Forms

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New Patient Forms

Welcome to The Spine & Pain Institute of New York. We look forward to meeting you! Below please find information packets containing all necessary forms for you to fill out prior to seeing one of our healthcare providers.

For your convenience, you may fill out these forms prior to your initial visit and bring with you to help expedite your visit. 

You may also email them prior to your appointment to: PatientSupport@spinepainny.com

Each packet contains the following forms:

  • Registration Form
  • HIPAA Form: Authorization for release of health information pursuant to HIPAA
  • Email/Text Policy Agreement: Authorization for communication from our practice via email/text messages
  • Voicemail Agreement: Authorization for our practice to leave you voice messages regarding your medical care.

New Patient: Major Medical/Private Insurance/Medicare 

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New Patient: No Fault/Workers’ Compensation Cases

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Procedure Forms

Please find the following forms below pertaining to your procedure:  

  • Medical Clearance Form: If you are over the age of 50 and would like to have sedation for your procedure, you are required by our anesthesiologists to obtain a medical clearance by your primary care physician prior to receiving sedation. If you are under 50 years old and have a medical condition that requires you to see a physician, we request that you obtain medical clearance as well. Sedation for procedures is optional and most procedures can be performed under local anesthesia only. Please bring the following medical clearance forms to your primary care physician and have them fill it out and bring it back with you to your scheduled procedure appointment. 
  • Request to Stop Anticoagulant Form: If you are taking a blood thinner medication you will need to see the physician responsible for prescribing this medication and obtain clearance to stop the medication for the appropriate time prior to your procedure. Please bring this form back with you to your scheduled procedure appointment.
  • Prior to Procedure Instructions: This form is available for you as a guideline to follow prior to your procedure. If you have specific medical problems, these should be addressed with your primary care physician when you obtain medical clearance for anesthesia. Please be sure to address any questions/concerns you may have with your physician or contact our office.
  • Post Procedure Instructions: This form is available for you as a guideline to follow after your procedure. Please be sure to address any questions/concerns you may have with your physician or contact our office. 

Procedure Forms

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Questions/Comments? 

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