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Home
About
- About Us
- Blog
Our Team
Conditions
Procedures
EMG / NCS Testing
Contact
- Contact Us
- Patient Referral

John Knightly, MD, FAANS

Spine Surgery

Gautam Malhotra, MD

Physiatry

Scott A. Meyer, MD, FAANS

Spine Surgery

Joseph Rempson, MD

Physical Medicine and Rehabilitation

Michael Rudman, MD

Interventional Pain Management

Terrence Welsh, MD

Interventional Pain Management

Richard Winne, MD

Interventional Pain Management

Jonathan J. Lee, MD

Spine Surgery

View All

Procedure Thoracic

Lumbar Procedure

Cervical Procedure

Condition Thoracic

Condition Lumbar

Condition Cervical

Title Image

New Patient Form – Physiatry

Thank you for requesting an appointment with our physiatry 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 - Physiatry

"*" indicates required fields

Step 1 of 4

25%

Name*

First Last

Email*

Phone*

Date of birth*

MM slash DD slash YYYY

Insurance*

Aetna

Blue Cross Blue Shield

Medicare

Aetna Medicare

Other

Other

Insurance Member ID*

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

MVA/PIP

Worker's Compensation

No

Which provider would you like to see?*

Dr. John Knightly

Dr. Scott Meyer

Dr. Jonathan Lee

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

No

Do you have recent imaging?*

MRI

CT

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)*

Prior Conservative Management

Have you trialed physical therapy?*

Yes

No

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

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

Yes

No

If yes, who is your pain management provider? (type n/a if no)*

If yes, what interventions have you tried and when were they done? (type n/a if no)*

Reason for Visit

Who referred you to Maxim Brain and Spine?*

Are you interested in surgery?*

Yes

No

Are you seeking a second opinion?*

Yes

No

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

Email

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

Maxim Health focuses on a collaborative team approach when treating our clients. Together, we can optimize your surgical journey and maximize client outcomes.

Office Hours

Monday – Friday: 9AM – 5 PM
Saturday: Closed
Sunday: Closed

Contact Information

New Jersey Offices
197 Ridgedale Ave, Suite 225
Cedar Knolls NJ 07927
310 Madison Avenue
Morristown, NJ 07960

(973) 206-1477

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