You can always press Enter⏎ to continue
Welcome to Global Neuro And Spine Institute- New Patient Forms
Welcome to Global Neuro And Spine Institute- New Patient Forms
 Please answer all questions.  The form can be filled out on your mobile phone, tablet or desktop computer.   This must be completed prior to your appointment along with the last step which directs you to our patient portal.  This will ensure faster check-in time at your visit. Please email Forms@globalneuroandspine.com with any questions.  Thank You!!
26Questions
New Patient Forms 
  • 1
    Press
    Enter
  • 2
    Pick a Date
    Press
    Enter
  • 3
    Please Select
    • Please Select
    • United States
    • Afghanistan
    • Albania
    • Algeria
    • American Samoa
    • Andorra
    • Angola
    • Anguilla
    • Antigua and Barbuda
    • Argentina
    • Armenia
    • Aruba
    • Australia
    • Austria
    • Azerbaijan
    • The Bahamas
    • Bahrain
    • Bangladesh
    • Barbados
    • Belarus
    • Belgium
    • Belize
    • Benin
    • Bermuda
    • Bhutan
    • Bolivia
    • Bosnia and Herzegovina
    • Botswana
    • Brazil
    • Brunei
    • Bulgaria
    • Burkina Faso
    • Burundi
    • Cambodia
    • Cameroon
    • Canada
    • Cape Verde
    • Cayman Islands
    • Central African Republic
    • Chad
    • Chile
    • China
    • Christmas Island
    • Cocos (Keeling) Islands
    • Colombia
    • Comoros
    • Congo
    • Cook Islands
    • Costa Rica
    • Cote d'Ivoire
    • Croatia
    • Cuba
    • Curacao
    • Cyprus
    • Czech Republic
    • Democratic Republic of the Congo
    • Denmark
    • Djibouti
    • Dominica
    • Dominican Republic
    • Ecuador
    • Egypt
    • El Salvador
    • Equatorial Guinea
    • Eritrea
    • Estonia
    • Ethiopia
    • Falkland Islands
    • Faroe Islands
    • Fiji
    • Finland
    • France
    • French Polynesia
    • Gabon
    • The Gambia
    • Georgia
    • Germany
    • Ghana
    • Gibraltar
    • Greece
    • Greenland
    • Grenada
    • Guadeloupe
    • Guam
    • Guatemala
    • Guernsey
    • Guinea
    • Guinea-Bissau
    • Guyana
    • Haiti
    • Honduras
    • Hong Kong
    • Hungary
    • Iceland
    • India
    • Indonesia
    • Iran
    • Iraq
    • Ireland
    • Israel
    • Italy
    • Jamaica
    • Japan
    • Jersey
    • Jordan
    • Kazakhstan
    • Kenya
    • Kiribati
    • North Korea
    • South Korea
    • Kosovo
    • Kuwait
    • Kyrgyzstan
    • Laos
    • Latvia
    • Lebanon
    • Lesotho
    • Liberia
    • Libya
    • Liechtenstein
    • Lithuania
    • Luxembourg
    • Macau
    • Macedonia
    • Madagascar
    • Malawi
    • Malaysia
    • Maldives
    • Mali
    • Malta
    • Marshall Islands
    • Martinique
    • Mauritania
    • Mauritius
    • Mayotte
    • Mexico
    • Micronesia
    • Moldova
    • Monaco
    • Mongolia
    • Montenegro
    • Montserrat
    • Morocco
    • Mozambique
    • Myanmar
    • Nagorno-Karabakh
    • Namibia
    • Nauru
    • Nepal
    • Netherlands
    • Netherlands Antilles
    • New Caledonia
    • New Zealand
    • Nicaragua
    • Niger
    • Nigeria
    • Niue
    • Norfolk Island
    • Turkish Republic of Northern Cyprus
    • Northern Mariana
    • Norway
    • Oman
    • Pakistan
    • Palau
    • Palestine
    • Panama
    • Papua New Guinea
    • Paraguay
    • Peru
    • Philippines
    • Pitcairn Islands
    • Poland
    • Portugal
    • Puerto Rico
    • Qatar
    • Republic of the Congo
    • Romania
    • Russia
    • Rwanda
    • Saint Barthelemy
    • Saint Helena
    • Saint Kitts and Nevis
    • Saint Lucia
    • Saint Martin
    • Saint Pierre and Miquelon
    • Saint Vincent and the Grenadines
    • Samoa
    • San Marino
    • Sao Tome and Principe
    • Saudi Arabia
    • Senegal
    • Serbia
    • Seychelles
    • Sierra Leone
    • Singapore
    • Slovakia
    • Slovenia
    • Solomon Islands
    • Somalia
    • Somaliland
    • South Africa
    • South Ossetia
    • South Sudan
    • Spain
    • Sri Lanka
    • Sudan
    • Suriname
    • Svalbard
    • eSwatini
    • Sweden
    • Switzerland
    • Syria
    • Taiwan
    • Tajikistan
    • Tanzania
    • Thailand
    • Timor-Leste
    • Togo
    • Tokelau
    • Tonga
    • Transnistria Pridnestrovie
    • Trinidad and Tobago
    • Tristan da Cunha
    • Tunisia
    • Turkey
    • Turkmenistan
    • Turks and Caicos Islands
    • Tuvalu
    • Uganda
    • Ukraine
    • United Arab Emirates
    • United Kingdom
    • Uruguay
    • Uzbekistan
    • Vanuatu
    • Vatican City
    • Venezuela
    • Vietnam
    • British Virgin Islands
    • Isle of Man
    • US Virgin Islands
    • Wallis and Futuna
    • Western Sahara
    • Yemen
    • Zambia
    • Zimbabwe
    • Other
    Press
    Enter
  • 4
    Press
    Enter
  • 5
    Press
    Enter
  • 6
    Press
    Enter
  • 7
    Press
    Enter
  • 8
    Please sign with cursor(if on desktop computer) or finger(if on mobile phone)
    Press
    Enter
  • 9

    IMPORTANT DISCLOSURE, AUTHORIZATION,
    ASSIGNMENT OF BENEFITS NOTICE AND BILL OF RIGHTS
    By signing below, I acknowledge that I understand the following:
    1. I hereby consent for treatment, consultation, or testing. I allow the provider, to release any
    information as required, in accordance with HIPPA guidelines.
    2. I hereby assign to Global Neuro and Spine Institute any benefits under any policy of insurance,
    indemnity agreement or any other collateral source as defined by Florida statues, for any services
    and /or charges provided by Global Neuro and Spine Institute It is the intent of the undersigned that
    this assignment be deemed irrevocable unless both the patient and an unauthorized representative
    for Global Neuro and Spine Institute execute a revocation of this Assignment of benefits prior to the
    filing of any suit for insurance benefits. The Assignment of Benefits shall apply to any and all
    causes of actions, suits, claims, counter-claims and demands.
    3. I hereby authorize all parties involved to release any and all documentation related to my care to
    Global Neuro and Spine Institute.
    4. I hereby authorize my attorney to release my settlement disbursement to Global Neuro and Spine
    Institute.
    5. Under Florida Law, physicians are generally required to carry malpractice insurance. Otherwise,
    they must demonstrate financial responsibility to cover potential claims for medical malpractice.
    Your doctor may have decided not to carry medical malpractice insurance. This is permitted under
    Florida law subject to certain conditions. Florida law imposes penalties against non-insured
    physicians who fail to satisfy adverse judgments arising from claims of medical malpractice. This
    notice is provided pursuant to Florida law.
    6. I agree and hereby authorize Global Neuro and Spine Institute to retain legal counsel of its choice in
    order to collect any and all outstanding balances as a result of treatment, services, or products
    provided, and to proceed against any insurance company for refusal to pay benefits due and owning
    under Florida law.
    1. If you need a referral from your insurance company or your primary care physician to be seen in
    our facility, the referral must be presented at the time of your visit. If it is not available, it will be
    your responsibility to obtain one. Consequently, you will need to reschedule your visit should the
    referral not be available. We encourage you to call your primary care physician and have your
    referral faxed to us. Our fax numbers can be obtained from the front desk.
    2. Many insurance companies require authorization or pre-authorization in order to have supplies
    and/or services dispensed by a doctor’s office or facility. Due to the many changes in insurance
    policies, it is no longer an easy task to interpret each individual policy. Although Global Neuro and
    Spine Institute tries to stay aware of these changes, it is not always possible; therefore, we urge you,
    the patient, to please check with your insurance company regarding your coverage. It is your
    responsibility to know your individual coverage and is limitations.
    Global Neuro and Spine Institute
    3. By rendering services and/or leaving the office with supplies that are not authorized, you will be
    financially responsible if your insurance company denies payment. In instances when your
    insurance company gives approval for care or services and later reverses its position, for whatever
    reason, you agree to be fully responsible for services rendered.
    4. If you have a co-payment or any out-of-pocket expense, deductible, etc.., it must be paid at the time
    services are rendered.
    5. I understand that I am responsible for any deductible or copayments under my insurance and that I
    am responsible for any charges should my insurance benefits become exhausted. I agree that in the
    event that it becomes necessary to collect monies owed by me, I will be responsible for all cost
    including, but not limited to, collection agency commissions, attorney fees and court costs. In
    addition, I agree to pay an interest charge of one and one half percent (11/2 %) per month on any
    balance after 45 days of service. Being carefully informed of these facts, I have decided to remain
    in the care of my physician and his associates.
    6. If for any reason you cannot keep your appointment, 24-hour notice must be given, otherwise
    a $50.00 fee will be charged.
    7. I HEREBY AUTHORIZE THE ASSIGNEE TO REQUEST ALL DOCUMENTS AND
    INFORMATION PERMITTED BY FLORIDA STATUTE SECTION 627.4137, INCLUDING
    BUT NOT LIMITED TO A COPY OF THE APPLICABLE INSURANCE POLICY,
    DECLARATION PAGE REFLECTING COVERAGE ON THE DATE OF LOSS, AND THE
    APPLICABLE PIP/LOG/LEDGER, ALL OF WHICH TO BE PROVIDED TO THE ASSIGNEE
    UPON REQUEST. This request is authorized pursuant to the terms of my policy as well as Florida
    Statutes 627.4137. I hereby authorize this assignee to request and receive a copy of my PIP
    Log/Ledger periodically.
    8. Be further advised that I AM HEREBY PLACING YOU ON NOTICE PERSUANT TO FLORIDA
    CASE LAW THAT SHOULD YOU (THE INSURANCE COMPANY/CARRIER) DENY,
    REDUCE, OR FAIL TO PAY ANY PART OF, OR AN ENTIRE BILL WHICH WAS
    SUBMITTED ON MY BEHALF FROM THIS PROVIDER, I (THE ASSIGNOR) AS WELL AS
    THE ASSIGNEE ARE REQUESTING IN ADVANCE THAT YOU RESERVE, OR “SETASIDE”, THE AMOUNT YOU
    RECEIVED OR DENIED UNTIL THE DISPUTE IS
    RESOLVED. Should you submit a check to assignee which is loss that the correct contractual
    amount, and contains any language referring to “Full and Final Payment” I have instructed
    Assignee to return the check to you (the carrier) and consider the bill still due and owing (i.e. A
    late payment as defined in F.S.S 627.736). Additionally, SHOULD THE REMAING AMOUNT
    OF MY BENEFITS APPROACH THE AMOUNT WHERE THERE WOULD BE
    INSUFFICIENT FUNDS TO PAY THE AMOUNT YOU REDUCED, DENIED, OR FAILED
    TO PAY, PLEASE NOTIFY ME (THE ASSIGNOR) AND THE ASSIGNEE OF THIS FACT.
    Should my benefits exhaust; please notify me (the assignor) and assignee promptly.

     

    Press
    Enter
  • 10
    Press
    Enter
  • 11
    Please sign with cursor(if on desktop computer) or finger(if on mobile phone)
    Press
    Enter
  • 12

    Formulary Benefits Data Consent Form

    Formulary Benefits data are maintained for health insurance providers by organizations
    known as Pharmacy Benefits Manager (PBM). PBM's are third party administrators of
    prescription drug programs whose primary responsibilities are processing and paying
    prescription drug claims. They also develop and maintain formularies, which are lists of
    dispensable drugs covered by a particular drug benefit plan.
    By signing below, I give permission for Global Neuro and Spine Institute to access my
    pharmacy benefits data, electronically through RxHub. This consent will enable Global
    Neuro and Spine Institute to:
    Determine the pharmacy benefits and drug co-pays for my health plan
    Check whether a prescribed medication is covered (in formulary) under my plan
    Display therapeutic alternatives with preference rank (if available) within a drug class for
    non-formulary medications
    Determine if my health plan allows electronic prescribing to Mail Order pharmacies, and
    if so, e-prescribe to these pharmacies
    Download a historic list of all medications prescribed for me by any provider

    Press
    Enter
  • 13
    Press
    Enter
  • 14
    Please sign with cursor(if on desktop computer) or finger(if on mobile phone)
    Press
    Enter
  • 15

    CANCELLATION AND NO SHOW POLICY

    Please be advised that if you must cancel your appointment, kindly provide our office with 24
    hours’ notice.
    Patients that do not show up for their scheduled appointments without a call to cancel will be
    considered a NO SHOW, and will be responsible for a$50.00 no show fee for the Office Visit
    and $100 for a Procedure Visit (Injection or EMG). This fee will be due at the next scheduled
    appointment.

    Press
    Enter
  • 16
    Press
    Enter
  • 17
    Please sign with cursor(if on desktop computer) or finger(if on mobile phone)
    Press
    Enter
  • 18

    CONSENT TO CALL

    By selecting I accept below, the patient is giving permission for the practice to use the
    information provided as part of the check in process to email and call the patient. This includes:
    Entry of any telephone contact number constitutes written consent to receive any automated,
    prerecorded, and artificial voice telephone calls initiated by the Practice. To alter or revoke this
    consent, visit the Patient Portal “Contact Preferences".

    CONSENT TO TEXT

    By selecting I accept below, the patient is giving permission for Global Neuro and Spine
    Institute to use the information provided as part of the check in process to text the
    patient. This includes: Entry of any telephone contact number constitutes written
    consent to receive on mobile phone any automated text alerts initiated by the Global
    Neuro and Spine Institute. To alter or revoke this consent, visit the Patient Portal
    “Contact Preferences". Text alerts may be about appointments, test results, and more.
    Select "I accept" if the patient has agreed to receive automated text alerts. Select "I
    decline" if the patient has declined

    Press
    Enter
  • 19
    Press
    Enter
  • 20
    Please sign with cursor(if on desktop computer) or finger(if on mobile phone)
    Press
    Enter
  • 21

    Zero Tolerance Agreement

    At Global Neuro and Spine Institute, we pride ourselves on providing a high standard of
    service to all our patients. In order for us to maximise the service we are able to give, we
    request patients agree to a number of practical measures.
    ❏ I will keep (and be on time for) all my scheduled appointments with the provider.
    ❏ If I need to cancel, I will notify the office within 24 hours of my scheduled appointment
    ❏ I will treat all practice staff and doctors with courtesy and respect. We work as a 'ZERO
    TOLERANCE' practice therefore any abrupt or rude behaviour exhibited either in the
    office, over the phone, or via correspondence may result in causes for discharge.
    ❏ I will not be disrespectful or disruptive to the staff if I owe a balance that is requiring
    payment either over the phone or at the time of appointment.
    ❏ I will keep the practice informed of up-to-date addresses and telephone numbers,
    especially if I’ve recently moved.
    ❏ I will participate in all treatment plans recommended by the provider.
    ❏ I will authorize my provider to seek contact from any/or all providers that have
    or are currently treating me.
    ❏ I will not allow another individual to contact the office on my behalf unless
    authorized by me.
    Your care is of our utmost concern. Should you have any complaint or suggestion to make
    about the services provided by the practice, you may contact the practice manager via your
    patient portal. If you do not have a patient portal, please request access from the medical
    staff during your appointment or you may call 1-800-735-1178 and one of our staff
    members can assist.

     

    Press
    Enter
  • 22
    Press
    Enter
  • 23
    Please sign with cursor(if on desktop computer) or finger(if on mobile phone)
    Press
    Enter
  • 24
    Drag and drop files here
    Select files to upload
    Max. file size: 10.6MB
    Cancelof
    Press
    Enter
  • 25

    COVID-19 

    Our goal is to continue to support patients and address their health care concerns during the COVID-19 pandemic. If you have an urgent need, please do not delay care, whether it is COVID-19 related or not. Our offices are taking extra precautions to ensure we can safely care for you. This includes robust patient screening, universal masking, and enhanced cleaning of patient, staff, and waiting areas.

     

     

    Preparing for your clinic appointment

     Our entire organization and all of its facilities are taking extra measures to keep patients safe when it is necessary for them to have an in-person appointment.

     We ask all patients to please follow the below temporary measures and aid us in our effort of keeping you and your care team,  and all of our patients safe.

     

     

    Prior to arriving

     We will continue to ask you a few questions when you schedule your appointment to help identify any symptoms or recent exposures you may have had to COVID-19.
    If any concerns are identified, our medical staff will reach out and determine if we need to update your appointment.

    During your appointment

     

     Patients in our clinics may have only ONE individual accompany them, with consideration for special exceptions determined by our care teams.
    All patients, visitors and staff are required to wear a mask to decrease the risk of COVID-19 exposure. Please bring your own face mask or covering to wear while at our facilities. The Center for Disease Control and Prevention has details on appropriate face coverings.
    Please do not bring children under the age of 13 unless they are actively receiving care in the clinic setting.
    Due to additional screening activities, when entering our buildings, please allow extra time upon arrival (approximately 15 minutes).
     

     

     

     

     

     

    Press
    Enter
  • 26

    THANK YOU

    PLEASE NOTE ONCE YOU HIT SUBMIT YOU WILL BE REDIRECTED TO OUR PATIENT PORTAL.

    1)PLEASE ENTER YOUR EMAIL FOR YOUR USERNAME

    2)TEMPORARY PASSWORD IS: Password1(Case Sensitive)

    3)PLEASE GO TO THE MY HEALTH SECTION AND FILL OUT YOUR MEDICAL HISTORY  

     

     

     

    If you have any issues please email info@globalneuroandspine.com

    Thank you very much.

    Press
    Enter
  • Should be Empty:
hipaa badge
Question Label
1 of 26See AllGo Back
close
Save & Continue Later

Your form is saved successfully!

If you want to continue answering your form later, please enter the email address you would like to send the link to:

Please enter a valid email address.

Something went wrong while saving your answers. Please try again.

Email has been sent successfully.

Save your progress

OR
Already have an account? LOGIN
Skip Create an Account

Save your progress

Terms of ServicePrivacy Policy

Your form submission has been saved as a draft.

If you want to continue answering your form later, please enter the email address you would like to send the link to:

Save your progress

OR
Forgot Password?

Your form submission has been saved as a draft.

We’ve sent you an email with a link to complete your submission.

Logout