Patient Resources: PATIENT INFORMATION


Our goal is to provide you with the best experience possible. We also know that your time is important. In order to save time and make your visit as stress-free as possible, please select and complete the appropriate forms (PDF format) prior to your visit.

The forms have been designed so that you can either type your answers into the form electronically, or you can print and write in your answers by hand.


New Patient Forms:

To be completed by all patients for the first visit to NovaSpine Pain Institute

This completed form:

  1. Provides us with your demographic and insurance information.  
  2. Helps the provider to evaluate, diagnose and treat your pain issues
  3. Give us a comprehensive look into your medical history, medications, previous treatments and ongoing issues.

Established Patients:

To be completed by all patients for each office visit.

  • This is a short, but comprehensive form that allows your provider to evaluate ongoing or worsening pain issues as well as provides useful information about changes to a patient's overall health status.

Sending your medical records to NovaSpine Pain Institute

Please download and print the NovaSpine Pain Institute Medical Record Release form. Please complete the form, sign it, and fax/mail/submit it to your previous doctors' office.

This form can also be completed and/or dropped off at a NovaSpine Pain Institute office during office hours, so that we can fax it over to your previous doctor's office.

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Medical Record Release Form (click to download, complete and print)

  • For West Valley (Sun City and Sun City West), please fax records to 623.777.4748
  • For East Valley (Gilbert, Mesa, Tempe/Chandler), please fax records to 480.771.4380

Commonly patients request the following items:

  1. Last few office visit notes
  2. All relevant procedure notes
  3. All MRI or CT scan reports
  4. All relevant operative/surgical reports

Financial Disclosure Form (already included in the new patient forms)

A physician must notify a patient that the physician has a direct financial interest in a separate diagnostic or treatment agency to which the physician is referring the patient and/or in the non- routine goods or services being prescribed by the physician, and whether these are available elsewhere on a competitive basis. A.R.S. §32-1401(27)(ff). We support this law, because it helps patients make reasoned financial decisions concerning their medical care.