Acute Injury Consultation Form

Required Practice Eligibility Verification

Thank you for your interest in Lexington Integrative Sports Medicine (LISM). Dr. Sri operates under a private, transparent, cash-pay direct care model, and federal law does not allow us to accept private-pay fees from Medicaid-enrolled individuals for services normally covered by Medicaid. Because of this, we're unable to process your booking at this time. We'd recommend reaching out to your primary care provider or another Medicaid-participating provider for these services. We apologize for any inconvenience, and wish you the best in your care.

Required Practice Eligibility Verification

Thank you for your interest in Lexington Integrative Sports Medicine (LISM).
Dr. Sri is currently in the formal process of officially opting out of Federal Medicare, with an anticipated effective date of October 1, 2026. Under CMS guidelines, until this opt-out is officially in effect, we are strictly prohibited from evaluating or treating Medicare beneficiaries under any cash-pay bundle or membership track.
We apologize for any inconvenience this causes.

Would you like us to contact you after October 1st, once Dr. Sri is officially opted out of Medicare?

Thank you so much for your interest in Lexington Integrative Sports Medicine — we wish you all the best in your care. You're always welcome to check back with us again in the future.

Name

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Did this sports or orthopedic injury occur within the last 2 weeks?

Thank you for contacting Lexington Integrative Sports Medicine (LISM). This visit type is designed for acute, active injuries requiring prompt evaluation, rather than long-standing or chronic pain.

We understand that recovery timelines vary. If your injury occurred slightly more than two weeks ago but remains an active issue limiting your mobility, this visit may still be appropriate. If so, please scroll back up, select "Yes," and complete this form.

However, if this is a chronic issue that has been present for some time, this visit is likely not the best fit. Please use our Comprehensive Integrative/Sports Medicine Consultation Form instead, so Dr. Sri can conduct a thorough review, including examining any prior imaging.

👉 Comprehensive Integrative/Sports Medicine Consultation Form

Thank you for helping us ensure every patient receives the care best suited to their needs.

Age

Required Acknowledgment: LISM Direct-Care (Youth) Pricing:

I understand that Lexington Integrative Sports Medicine (LISM) is a direct, transparent, cash-pay practice with no insurance middleman. I acknowledge and agree that my Acute Injury Recovery Bundle fee is a flat $150. This includes a focused initial assessment with a fellowship-trained sports medicine physician, one complimentary follow-up check-in to safely guide your recovery, and up to 6 weeks of secure messaging access to Dr. Sri and his nurse co-pilot via the Spruce app. It also includes referral coordination with local physical therapists or imaging centers if advanced diagnostics are needed.

Required Acknowledgment: LISM Direct-Care (Adults) Pricing:

I understand that Lexington Integrative Sports Medicine (LISM) is a direct, transparent, cash-pay practice with no insurance middleman. I acknowledge and agree that my Acute Injury Recovery Bundle fee is a flat $225. This includes a focused initial assessment with a fellowship-trained sports medicine physician, one complimentary follow-up check-in to safely guide your recovery, and up to 6 weeks of secure messaging access to Dr. Sri and his nurse co-pilot via the Spruce app. It also includes referral coordination with local physical therapists or imaging centers if advanced diagnostics are needed.

Affected Joint Area

What Happened? "In 1–2 brief sentences, please tell us how and when the injury occurred."

How would you like us to reach you about scheduling? (Check all that apply)

What's the best time to reach you by phone?

What are your preferred treatment windows? (Please Select at least 3) ?

Rows	8am-10am	10am - 12pm	12pm - 2pm	2pm - 4pm
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Consent

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Acute Injury consultation Form