Interventional Pain Appointment Request

Important Information

This is an appointment request. Please provide all of the applicable information requested with as much detail as possible to speed up the scheduling process. We will verify insurance and review prior treatment before giving you a call to book your appointment. All of the information provided here will be sent to us securely.

Delmarva Pain and Spine Center (Newark, DE)

Thanks for choosing us for your care!

Your name

Date of Birth

Gender

Male Female

Referring Provider

If you were referred to us, please provide the referring doctor or practice's name. Otherwise, state self-referred.

Primary Care Doctor

Pharmacy

Please let us know what pharmacy you prefer to use for any future prescriptions. State name & location.

Phone Number (with area code)

Email Address

PRIMARY Health Insurance Carrier Name

If no insurance, state "self-pay" in both fields.

Insurance ID #

SECONDARY Health Insurance Carrier Name

Insurance ID #

Work or Motor Vehicle Accident Injuries (if applicable)

Are you seeking care related to an injury from an accident (e.g. work or motor vehicle)?

Yes No

What Type of Accident?

Motor Vehicle Accident (Personal Injury) Work Accident (Workers Compensation)

Date of Accident

Attorney's Name

Enter "NONE" if you are not working with one.

Attorney's Phone Number

Accident Insurance Carrier Name

Accident Claim #

Adjustor's Name (if available)

Adjustor's Phone # (if available)

Mark the areas on the image where you are experiencing symptoms

Describe your Issue

Include any additional information about prior treatment completed (e.g. chiropractic, physical therapy, etc.)

Medications

Tell us about any medications you take for pain, if any.

Prior Imaging

Tell us about any imaging (CT, X-ray, MRI, etc.) performed recently, if any.

Upload Files If you have any written referrals, reports, or records you would like to share with us, please feel free to upload them here.

Add file

Please upload a file

NOTE:

Please note that this is only an appointment REQUEST and booking times are subject to availability. We will give you a call to officially book your appointment once we obtain all necessary insurance information and prior treatment records (e.g. office visit notes, X-ray / MRI imaging reports, etc.)

CONSENT:

By submitting this appointment request form, I hereby consent and state my preference to have my physician and other staff at Delmarva Pain and Spine Center, LLC communicate with me by email or standard SMS messaging regarding aspects of my medical care, appointments, and billing. I understand that email and standard SMS may be insecure, and if used improperly, could potentially be intercepted by third-party. Submission of this form is secure.

I Accept

Your information will be encrypted.