Our Contact Information
Phone: (701) 248-8126 | Address: 3174 Sienna Dr S, Suite 101, Fargo ND 58104 | mahajanspineandjoint@gmail.com
New Patient Form
This form is HIPAA compliant (your information is secure). Collecting this information will allow us to move forward in the scheduling process.
Step 1: Demographic Information
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Do you give us permission to communicate with you via text (SMS) messaging?
*
Yes (Recommended)
No
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Step 2a: Insurance Information
Primary Insurance (Medicare, BCBS ND, etc.)
*
Secondary Insurance (Champ VA, BCBS MN Select Care, etc.)
Step 2b: Insurance Cards
Please either take pictures of your insurance cards as prompted below or submit pictures of your insurance cards by uploading the files at the bottom of the page. We cannot schedule your appointment until we have received your insurance cards.
Front of Insurance Card #1
Back of Insurance Card #1
Front of Insurance Card #2
Back of Insurance Card #2
Front of Insurance Card #3
Back of Insurance Card #3
File Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
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Step 3: Clinical Information
The following information will help us triage your care efficiently.
Where is your pain located for which you would to visit? (Low back, neck, knee, etc.)
Have you seen Dr. Mahajan within the past three years for care?
Yes
No
Would you like to repeat an injection that he performed or come in for a clinic visit?
Repeat Injection
Come in for a clinic visit
Which of the following have you completed for your current pain area?
X-ray
CT ccan
MRI
Physical therapy
Chiropractic care
Over the counter medications
Prescription medications
Injections
Surgeries
Where was the MRI performed?
Release of Information
If you authorize release of information (your medical records) from other health systems to our clinic, please sign below. This will help to expedite your care at our clinic.
Signature
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Should be Empty: