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.

New Patient Form

"*" indicates required fields

Step 1 of 4

25%

X/Twitter

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

CAPTCHA

Formulario para nuevos pacientes

"*" indicates required fields

Step 1 of 4

25%

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*

This field is hidden when viewing the form

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%

Instagram

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

CAPTCHA

BOOK APPOINTMENT

New Patient Form

Formulario para nuevos pacientes

New Patient Form

Locations

New Jersey Offices

Cedar Knolls

Morristown

Bridgewater

Summit