I certify that I, and/or my dependents have insurance coverage with the insurance company and information previously stated within this form and assign directly to The Spine Care Institute (Dr. Edward O'Brien) all insurance benefits, if any, otherwise payable to me for services rendered.  I understand that I am financially responsible for all charges whether or not paid by insurance.  I authorize the use of my electronic acceptance (Signature) on all insurance submissions.

The above named doctor may use my health care insurance information and may disclose such information to the named insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services.  This consent will end when my current treatment plan is completed or one year from the date I submit this online form.

I understand that by entering my name in the box below, it consitutes as my electronic signature an will be validated as such.

Please provide the name & address of other doctor(s) who have treated you for your condition and please provide the date of your last -

• Physical Exam
• Spinal X-Ray
• Blood Test
• Spinal Exam
• Chest X-Ray
• Urine Test
• Dental X-Ray
• MRI, CT-Scan, Bone Scan

Please tell us about any surgeries or injuries you have had.  Please include any:

• Falls
• Head Injuries
• Broken Bones
• Dislocations
• Surgeries

Please provide us the date of the injury / surgery too...  Please be as specific as you can.  If you have had none, please enter n/a in the box

Please list all your medications, allergies and vitamins/herbs/minerals you are currently taking.  Please tell us your pharmacy name and phone number.  If you are not taking any of these, please enter n/a in the box