Referral Screening Form

Referral Screening Form
Full Name:

First NameLast Name
Email:
example@example.com
Phone Number:
Please enter a valid phone number.
Date of Birth:*

MonthDayYear
Date
How did you hear about Seaside Spine Specialists?

Internet Search (Google, Bing, Yahoo, etc)A friend or family member recommended Seaside SpineMy primary care doctor referred meI saw an advertisement for Seaside Spine
May we have the name of the person who referred you so we may thank them?
What device are you using to complete this form? (this will help us recommend a way of uploading your MRI report)*

I am using my phone/tabletI am using my computer
What is your employment status?*

EmployedRetiredSelf-employedDisabledUnemployed
Tap here to take a photo of the FRONT of your PRIMARY insurance card.

Cancelof
Tap here to take a photo of the BACK of your PRIMARY insurance card.

Cancelof
You told us you were using a computer to complete this form. Would you rather type in your insurance card information or do you have a scanned copy of your card saved on your computer?

I would like to manually type in my insurance card information.I have a scanned copy of my card and I would like to upload that file.
Please type your insurance card information below.
Please upload you insurance card information here.

Cancelof
Where is your greatest pain?*

Neck and Arm pain or numbnessThoracic pain or numbness (your thoracic spine is your mid-back, above your lumbar spine and below your cervical spine)Low back pain or leg pain/numbnessIt hurts everywhere, all the time
Are your symptoms related to an accident of any kind?*

NoYES
Is this a work related injury related under a Workers Compensation claim?*

NoYES
Have you recently been seen in the Emergency Room due to an injury?*

NoYES
Which hospital were you recently seen at?

Trident or Summerville Medical CenterRoper Hospital (includes Roper St Francis, Roper Downtown, Roper Berkeley and Roper Mt Pleasant)East Cooper Medical Center in Mount PleasantMUSCOther
Is this injury related to a:*

Motor vehicle accidentSlip/FallOther
Do you have an active legal case or considering taking legal action?*

NoYES
What is the name & phone number of the Attorney and/or Law Firm?*
Who is your primary care doctor?
Do you have a pain management doctor? (this is a physician why typically writes for narcotics and likely has done steroid injections in your neck or low back using a needle)

YesNo
Who is your pain management doctor?
If you don't know their name, then you can tell us the name of the practice or perhaps the part of town in which the practice is located.
How many cervical (neck) surgeries have you had?
How many lumbar (low back) surgeries have you had?
When was your last surgery?
Do you remember the name of your spine surgeon who performed your most recent spine surgeries?

Dr. Sunil Patel (MUSC)Dr. Stephen Kalhorn (MUSC)Dr. Alex Vandergrift (MUSC)Dr. Bruce Frankel (MUSC)Dr. Steven Morgan (MUSC)Dr. Nathan Rowland (MUSC)Dr. Istvan Takacs (MUSC)Dr. Abhay Varma (MUSC)Dr. Lee Leddy (MUSC)Dr. Reitman (MUSC)Dr. John Glaser (MUSC)Dr. Brian Cuddy (Roper)Dr. Curtis Worthington (Roper)Dr. Byron Bailey (Roper)Dr. Artur Paccult (Roper)Dr. Clayton Halderman (Roper)Dr. Steven Rawe (Roper)Dr. George Khoury (Roper)Dr. Matthew Neal (Roper)Dr. John Steichen (Roper)Dr. Morgan Stuart (Roper)Dr. Stephen Poletti (Southeastern Spine)Dr. Richard Frisch (Southeastern Spine)Dr. Thomas Anderson (Southeastern Spine)Dr. Timothy Bryan (Southeastern Spine)Dr. Benjamin Schell (Southeastern Spine)Dr. Mark Hartman (Southeastern Spine)Dr. Don Stovall (Lowcountry Orthopedics)Dr. Chris Battista (Lowcountry Orthopedics)Dr. Todd Lansford (South Carolina Sports Medicine)Dr. Mike Tyler (North Charleston)Dr. Mike Marzluff (North Charleston)Dr. Jason Highsmith (North Charleston)Dr. Doug Stofko (Trident Health)Dr. Sharon Webb (Trident Health)Dr. Michael Wildstein (West Ashley)Dr. Jeffrey Reuben (Beaufort, Hilton Head)Dr. Craig Boatright (Beaufort, Bluffton, Hilton Head)Dr. Scott Strohmeyer (Beaufort, Bluffton, Hilton Head)Dr. Andrew Castro (Beaufort, Bluffton, Hilton Head)Other
Do you remember which hospital you had your most recent spine surgeries?

Roper Hospital (includes Roper St Francis, Roper Downtown, Roper Berkeley and Roper Mt Pleasant)East Cooper Medical Center in Mount PleasantTrident or Summerville Medical CenterMUSCBeaufort Memorial HospitalOrangeburg Medical CenterPrisma Health SystemHilton Head HospitalMcLeod Health SystemOther
Have you had a recent MRI of your spine (hint: an MRI is a long tube that you lay in for about 20 minutes. You are usually given headphones because the machine is loud. Dont confuse this with a Cat Scan, or CT Scan, which is a short tube and the scan only takes 5 minutes or less.)*

Yes, I have done an MRI within the last 12 monthsNo, I have not done an MRI
Was your recent MRI done at one of the following facilities (select all that apply)?

Medical University of South Carolina (MUSC)Trident Medical Center (TMC)Summerville Medical Center (SMC)Colleton Medical Center (CMC)Roper Downtown CharlestonRoper St. FrancesRoper BerekelyRoper Mt PleasantEast Cooper Medical Center (ECMC)Beaufort Memorial Hospital (BMH)Tricounty RadiologyImaging SpecialistsAxis 3T MRIAmerican Health ImagingPalmetto Primary Care Diagnostic Imaging CenterMRI of Charleston (Pain Specialists of Charleston)Lowcountry Orthopaedics**NO, MY MRI WAS DONE SOMEWHERE ELSE**
Great! With your permission, we can remotely access your imaging. Do you give us permission to remotely access your imaging?*

YesNo
If you selected 'NO,' then you have three options for getting us your imaging. No need to complete this now. These instructions will be emailed to you once you submit the form.

First you will need to call or visit the imaging center and ask them to put your imaging on a CD. Then you can do any one of the following:

1. Mail us the MRI CD:

Seaside Spine Specialists

9565 Highway 78, Building 100

Ladson, SC 29456

2. If you have a CD reader on your home computer, then follow these instructions:

Upload your MRI CD from home by clicking this link:

Seaside Spine MRI CD Uploader

3. If you do NOT have a CD reader on your home computer, then follow these instructions:

Upload your MRI CD from your local CVS:

Take your CD to the Photo Kiosk at any CVS.

Click on the screen and select "My Medical Images."

Create a free account.

Click the option that says "Share images with my Doctor."

Then, when prompted, type in Seaside1 to select our practice as the destination for your imaging files. You will get your CD back once the files are uploaded.
Do you have a copy of your MRI report?

YesNo
Since you are using a phone/tablet, it would be easiest to take a picture of the report? Click here to take a photo of page #1.

Cancelof
Click here to take a photo of page #2.

Cancelof
Click here to take a photo of page #3 (if you have a third page).

Cancelof
Since you are using a computer, it would be easiest to upload the file here:

Cancelof
Thank you for completing this questionnaire. The act of submitting this form, with or without imaging information, does not create a patient-physician treatment relationship. Once submitted, our expert medical team will review your information. After our review, our office may contact you. At that time, our medical team will discuss your options for scheduling a formal appointment with our spine specialistsl. By sharing your medical images, you acknowledge and agree to the following:

1. That your personally identifiable health care information can be shared with employees of Seaside Spine Specialists.

2. That the image review is providing only an informational review of the documents that you are providing and does not create nor constitute a physician patient relationship.

3. That the information provided by our providers is not a form of diagnosis. A diagnosis can only be made if you have been physically examined by a Seaside Spine Specialists’ provider.

Upon receipt of your information, Seaside Spine Specialists will NOT share your personally identifiable health care information with third parties without your written consent.
I have read the above and understand that I am giving Seaside Spine Specialists permission to review my information, including radiographic images and report(s) and that this does not create a patient-physician relationship.*

I agreeI do not agree or I do not understand
Signature (use your finger or mouse)

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