New Patient Inquiry Form

New Patient Inquiry Form

Let us know how we can help you!
Please fill out this form in its entirety providing as much information as possible. Due to the volume of new patient inquiries we are currently receiving, response time is 5 - 7 days. We appreciate your patience as our team works to provide the best care possible to our current and future patients. To expedite your appointment, please have your referring Physician fax us your referral form and all records to 912.298.6622
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Number*
Please enter a valid phone number.
Email Address*
example@example.com
Date of Birth:*

MonthDayYear
Date
Sex:*

MaleFemale
Please describe your problem/concern as well as any symptoms you are experiencing: *
Referring/Primary Care Physician: *
Have you seen a Neurologist/Sleep Specialist before?*

YesNo
If yes, who? *
Is there any legal involvement with your case? (ex: motor vehicle accident, workers comp)*

YesNo
Are you currently receiving disability for this problem or plan to apply for disability?*

YesNo
Health Insurance

We are in network with most insurance providers. In some instances we will accept self-pay.
We do not accept the following insurance plans. This is not an exhaustive list and it is the responsibility of the patient to verify network status with their insurance provider. Please note, if your secondary insurance is out of network, the patient is responsible for any balance due after the primary insurance has paid. This includes deductibles, copays and co-insurance amounts.

-Medicaid
-Blue Cross Blue Shield Exchange Plans

By initialing below, I understand that I am financially responsible for any balance due that is not covered by my Primary Insurance. I understand that the above listed insurances are not in network.
Patient Initials: Initial here*
Who is your health Insurance provider?*
Upload Insurance Card here. Please include both the front and back of your card.

Cancelof
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New Patient Inquiry Form

Health Insurance