BOOK APPOINTMENT

Thank you for requesting an appointment with our surgical team. If this is your first time visiting us – please complete the form below and then one of our team members will contact you shortly to schedule your initial appointment.

If you don’t receive an email confirmation, the submission may not have gone through. Please double-check your details and try the process again.

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Company

This field is for validation purposes and should be left unchanged.

Name*

First Last

Email*

Phone*

Date of birth*

MM slash DD slash YYYY

Insurance*

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Insurance*

Aetna

Blue Cross Blue Shield

Medicare

Aetna Medicare

Other

Insurance Member ID*

Is this an MVA/PIP or Worker's Compensation case?*

MVA/PIP

Worker's Compensation

Please briefly describe the reason for your appointment including your current symptoms.*

Which provider would you like to see?*

Dr. John Knightly

Dr. Scott Meyer

Dr. Jonathan Lee

Dr. Mousa Hamad

Next Available Provider

Medical History (List any prior diagnoses, e.g. hypertension):*

Medications (Include all prescriptions and supplements):*

Allergies*

Height*

Weight*

Smoking Status*

Non-smoker

Current smoker

Functional Status*

Independent

I use a cane

I use a walker

I am wheelchair bound

Occupation*

Have you had previous spine surgery?*

Yes

What Type of Surgery Did You Have?*

Who Performed Your Surgery?*

When Did Surgery Take Place?*

Do you have recent imaging?*

MRI

X-ray

No imaging

Other

Other:

Where was your imaging completed? (type n/a if no imaging)*

Approximately when was your imaging completed? (type n/a if no imaging)*

Have you had a recent DEXA bone density study?*

Yes

What is the approximate date of the DEXA study?*

Prior Conservative Management

Have you tried physical therapy?*

Yes

If yes, approximately how long ago? (type n/a if no)*

Have you tried pain management? (e.g. epidural steroid injection, facet injection, radiofrequency ablation)*

Yes

If yes, who is your pain management provider?*

If yes, what interventions have you tried and when were they done?*

Reason for Visit

Who referred you to Maxim Brain and Spine?*

Are you interested in surgery?*

Yes

Are you seeking a second opinion?*

Yes

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Formulario para nuevos pacientes

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Comments

This field is for validation purposes and should be left unchanged.

Nombre*

First Last

Correo electrónico*

Teléfono*

Fecha de Nacimiento*

MM slash DD slash YYYY

Seguro médico*

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Seguro médico*

Aetna

Blue Cross Blue Shield

Medicare

Aetna Medicare

Other

Número de identificación de miembro del seguro*

¿Es este un caso de accidente automovilístico / protección contra lesiones personales o de compensación laboral?*

MVA/PIP

Compensación Laboral

Describa brevemente el motivo de su cita, incluidos sus síntomas actuales.*

¿Qué doctor le gustaría ver?*

Dr. John Knightly

Dr. Scott Meyer

Dr. Jonathan Lee

Dr. Mousa Hamad

Siguiente doctor disponible

Historial médico (enumere cualquier diagnóstico previo, por ejemplo, hipertensión)*

Medicamentos (incluya todas las prescripciones y suplementos)*

Alergias*

Altura*

Peso*

¿Es fumador?*

Non-smoker

Current smoker

Estado Funcional*

Independiente

Uso un bastón.

Uso un anador.

Uso una silla de ruedas.

Ocupación*

¿Ha tenido alguna cirugía de columna previamente?*

What Type of Surgery Did You Have?*

Who Performed Your Surgery?*

When Did Surgery Take Place?*

Do you have recent imaging?*

MRI

X-ray

No imaging

Other

Other:

Where was your imaging completed? (type n/a if no imaging)*

Approximately when was your imaging completed? (type n/a if no imaging)*

Have you had a recent DEXA bone density study?*

Yes

What is the approximate date of the DEXA study?*

Prior Conservative Management

Have you tried physical therapy?*

Yes

If yes, approximately how long ago? (type n/a if no)*

Have you tried pain management? (e.g. epidural steroid injection, facet injection, radiofrequency ablation)*

Yes

If yes, who is your pain management provider?*

If yes, what interventions have you tried and when were they done?*

Reason for Visit

Who referred you to Maxim Brain and Spine?*

Are you interested in surgery?*

Yes

Are you seeking a second opinion?*

Yes

CAPTCHA

New Patient Form

"*" indicates required fields

Step 1 of 4

25%

This field is for validation purposes and should be left unchanged.

Name*

First Last

Email*

Phone*

Date of birth*

MM slash DD slash YYYY

Insurance*

This field is hidden when viewing the form

Insurance*

Aetna

Blue Cross Blue Shield

Medicare

Aetna Medicare

Other

Insurance Member ID*

Is this an MVA/PIP or Worker's Compensation case?*

MVA/PIP

Worker's Compensation

Please briefly describe the reason for your appointment including your current symptoms.*

Which provider would you like to see?*

Dr. John Knightly

Dr. Scott Meyer

Dr. Jonathan Lee

Dr. Mousa Hamad

Next Available Provider

Medical History (List any prior diagnoses, e.g. hypertension):*

Medications (Include all prescriptions and supplements):*

Allergies*

Height*

Weight*

Smoking Status*

Non-smoker

Current smoker

Functional Status*

Independent

I use a cane

I use a walker

I am wheelchair bound

Occupation*

Have you had previous spine surgery?*

Yes

What Type of Surgery Did You Have?*

Who Performed Your Surgery?*

When Did Surgery Take Place?*

Do you have recent imaging?*

MRI

X-ray

No imaging

Other

Other:

Where was your imaging completed? (type n/a if no imaging)*

Approximately when was your imaging completed? (type n/a if no imaging)*

Have you had a recent DEXA bone density study?*

Yes

What is the approximate date of the DEXA study?*

Prior Conservative Management

Have you tried physical therapy?*

Yes

If yes, approximately how long ago? (type n/a if no)*

Have you tried pain management? (e.g. epidural steroid injection, facet injection, radiofrequency ablation)*

Yes

If yes, who is your pain management provider?*

If yes, what interventions have you tried and when were they done?*

Reason for Visit

Who referred you to Maxim Brain and Spine?*

Are you interested in surgery?*

Yes

Are you seeking a second opinion?*

Yes

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Locations

Verona

799 Bloomfield Ave, Suite 112,
Verona, NJ 07044

BOOK APPOINTMENT

New Patient Form

Formulario para nuevos pacientes

New Patient Form

Locations

New Jersey Offices

Cedar Knolls

Morristown

Bridgewater

Summit

New Location Coming Soon!*

Verona