Appointment Form

1
Are you a new patient to Southeastern Spine?* This field is required.A new patient has never been seen at SSI or hasn't been seen in the last 3 years
yesno
2
How were you referred to Southeastern Spine?* This field is required.
TV commercial
Physician referral
Internet
Word of mouth
Family or friend
Attorney
Other
3
Referring Physician Name* This field is required.
4
Patient Name* This field is required.
First Name
Middle Name
Last Name
5
Patient Date of Birth* This field is required.
Date
Month
Day
Year
6
Has your address changed since you were last seen at SSI?* This field is required.
YESNO
7
Patient Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
8
Has your email changed since you were last seen at SSI?* This field is required.
YESNO
9
Patient Email* This field is required.
example@example.com
10
Has your mobile phone number changed since you were last seen at SSI?* This field is required.
YESNO
11
Patient Mobile Phone Number* This field is required.
Please enter a valid phone number.
12
Has your primary insurance changed since you were last seen at SSI?* This field is required.
YESNO
13
Do you have current Health Insurance?* This field is required.
YESNO
14
Primary Insurance Company Name* This field is required.Ex. Medicare, Blue Cross, United, Aetna
15
Insured Name* This field is required.This might be you, a spouse, or a parent. You can type "me" if it is you.
16
Insured Date of Birth* This field is required.This is the date of birth of the insured
Date
Month
Day
Year
17
Insured Member ID* This field is required.This is the ID number of the insured
18
Is there a Secondary Insurance?* This field is required.This is also known as supplemental insurance.
YESNO
19
Has your secondary insurance changed since you were last seen at SSI?* This field is required.
YESNO
20
Secondary Insurance Company Name* This field is required.
21
Secondary Insured Name* This field is required.This might be you, a spouse, or a parent. You can type "me" if it is you.
22
Secondary Insured Date of Birth* This field is required.
Date
Month
Day
Year
23
Secondary Insurance Member ID* This field is required.
24
Would you like to schedule an online Telemedicine appointment?* This field is required.You will be scheduled initially with a Southeastern Spine Physician Assistant. The PA will gather information about your problem, schedule appropriate tests and schedule you a rapid follow-up with one of our Physicians. This is often the fastest way to get started, especially for our patients that live a further distance from our office.
YESNO
25
Schedule your Telemedicine Appointment* This field is required.If you can't find a date and time that works for you, please click Previous and select "No" on the previous question.
26
Great! You've selected {scheduleYour} for your appointment date and time. Click Submit and your appointment will be scheduled. You will then be redirected to provide us with some additonal required information.
27
What symptoms or issues are you having?* This field is required.
28
How soon would you like to be seen in the office?* This field is required.You can request a specific date and time or doctor and we will do our best to accommodate you.
29
Would you like to fill out our new patient form now?* This field is required.This will help you get seen sooner and cut down on wait time in the office.
YESNO
30
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