Hi David, let’s get ready for your visit.

The Spine Pro on Monday, June 8 at 5:30 PM.

Takes about 5 minutes.

Answers save automatically as you go.

Does this time work?

Monday, June 8

5:30 PM

New Patient Initial Consult · Dr. Melamed

Yes, this worksI need a different time

What times work better?

Anything else? (optional)

What brings you in?

How is your pain today?

Slide to choose 0 to 10.

7

No painWorst pain

Insurance

Optional. You can upload your card now, type details, or bring it to the visit.

Upload or type my insurance nowAlready on fileI’ll bring my cardSelf-pay

Upload card photos or a PDF

JPG, PNG, WebP, or PDF. Max 10 MB each. Uploading is optional and stored privately for staff review.

Primary card frontChoose filePrimary card backChoose fileSecondary card or extra fileChoose file

Assignment of Benefits

Lets the clinic bill your insurance on your behalf.

I reviewed the Assignment of Benefits & Limited Power of Attorney and agree that my typed name is my electronic signature for that form.

Type your full legal name

Notice of Privacy Practices

How your health info is protected.

I reviewed/received the Notice of Privacy Practices and agree that my typed name is my electronic signature for that acknowledgement.

Type your full legal name

Office Financial Policy

Cancellations, insurance, consent.

I reviewed the Office Financial Policy forms and agree that my typed name is my electronic signature for those forms.

Full legal name

Type your full legal name

Anti-Inflammatory Diet

I reviewed the Anti-Inflammatory Diet handout and acknowledge receipt electronically.

Recommended Supplements

I reviewed the Recommended Supplements handout and acknowledge receipt electronically.

Optional release

The Spine Prosometimes shares patient before/after photos or quotes in marketing materials — website, social media, brochures.

This is fully optional. Your care is not affected either way.

If you opt in, you can revoke this consent at any time by contacting the clinic in writing.

DeclineOpt in

Sign the release

Type your full legal name

Electronic signature consent

One last consent for the whole packet.

I consent to receive, review, sign, and retain these pre-visit records electronically. I understand I may request a paper copy from the clinic, and that checking the signature boxes and typing my name will be treated as my electronic signature for this packet.

Review

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