{"id":680,"date":"2022-11-28T19:35:23","date_gmt":"2022-11-28T19:35:23","guid":{"rendered":"https:\/\/backinstituteneurosurgery.com\/web\/?page_id=680"},"modified":"2025-10-11T08:55:22","modified_gmt":"2025-10-11T08:55:22","slug":"new-patient-form-cervical","status":"publish","type":"page","link":"https:\/\/backinstituteneurosurgery.com\/main\/new-patient-form-cervical\/","title":{"rendered":"New Patient Form \u2013 Cervical"},"content":{"rendered":"<p>Initial Inquiry Form<br \/>\nThis is a CONFIDENTIAL questionnaire to help us determine the best treatment plan for you. Please fill out this questionnaire<\/p>\n<div class=\"mobile-only-text\">\n<strong>At this time, our practice is not affiliated with a trial.<\/strong>\n<\/div>\n<div class=\"wpforms-container wpforms-container-full wpforms-render-modern\" id=\"wpforms-898\"><form id=\"wpforms-form-898\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"898\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/main\/wp-json\/wp\/v2\/pages\/680\" data-token=\"87b134e3f3a29081556a84349b811ef0\" data-token-time=\"1776005462\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-hidden\" id=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/div><div class=\"wpforms-field-container\"><div id=\"wpforms-898-field_0-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"0\"><label class=\"wpforms-field-label\" for=\"wpforms-898-field_0\">Name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-898-field_0\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][0]\" aria-errormessage=\"wpforms-898-field_0-error\" required><\/div><div id=\"wpforms-898-field_55-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"55\"><label class=\"wpforms-field-label\" for=\"wpforms-898-field_55\">Name of Spouse<\/label><input type=\"text\" id=\"wpforms-898-field_55\" class=\"wpforms-field-medium\" name=\"wpforms[fields][55]\" aria-errormessage=\"wpforms-898-field_55-error\" ><\/div><div id=\"wpforms-898-field_1-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"1\"><label class=\"wpforms-field-label\" for=\"wpforms-898-field_1\">Email <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-898-field_1\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][1]\" spellcheck=\"false\" aria-errormessage=\"wpforms-898-field_1-error\" required><\/div><div id=\"wpforms-898-field_3-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"3\"><label class=\"wpforms-field-label\" for=\"wpforms-898-field_3\">Address<\/label><input type=\"text\" id=\"wpforms-898-field_3\" class=\"wpforms-field-medium\" name=\"wpforms[fields][3]\" aria-errormessage=\"wpforms-898-field_3-error\" ><\/div><div id=\"wpforms-898-field_4-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"4\"><label class=\"wpforms-field-label\" for=\"wpforms-898-field_4\">City <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-898-field_4\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][4]\" aria-errormessage=\"wpforms-898-field_4-error\" required><\/div><div id=\"wpforms-898-field_5-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"5\"><label class=\"wpforms-field-label\" for=\"wpforms-898-field_5\">State <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-898-field_5\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][5]\" aria-errormessage=\"wpforms-898-field_5-error\" required><\/div><div id=\"wpforms-898-field_6-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"6\"><label class=\"wpforms-field-label\" for=\"wpforms-898-field_6\">Zip Code<\/label><input type=\"text\" id=\"wpforms-898-field_6\" class=\"wpforms-field-medium\" name=\"wpforms[fields][6]\" aria-errormessage=\"wpforms-898-field_6-error\" ><\/div><div id=\"wpforms-898-field_7-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"7\"><label class=\"wpforms-field-label\" for=\"wpforms-898-field_7\">Phone Number <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-898-field_7\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][7]\" aria-errormessage=\"wpforms-898-field_7-error\" required><\/div><div id=\"wpforms-898-field_8-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"8\"><fieldset><legend class=\"wpforms-field-label\">Best time for us to call you<\/legend><ul id=\"wpforms-898-field_8\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-898-field_8_1\" name=\"wpforms[fields][8][]\" value=\"Any Time\" aria-errormessage=\"wpforms-898-field_8_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-898-field_8_1\">Any Time<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-898-field_8_2\" name=\"wpforms[fields][8][]\" value=\"1st Half of the Day\" aria-errormessage=\"wpforms-898-field_8_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-898-field_8_2\">1st Half of the Day<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-898-field_8_3\" name=\"wpforms[fields][8][]\" value=\"2nd Half of the Day\" aria-errormessage=\"wpforms-898-field_8_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-898-field_8_3\">2nd Half of the Day<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-898-field_9-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"9\"><label class=\"wpforms-field-label\" for=\"wpforms-898-field_9\">Are you the Patient? If no, please tell us<\/label><input type=\"text\" id=\"wpforms-898-field_9\" class=\"wpforms-field-medium\" name=\"wpforms[fields][9]\" aria-errormessage=\"wpforms-898-field_9-error\" ><\/div><div id=\"wpforms-898-field_12-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"12\"><fieldset><legend class=\"wpforms-field-label\">Areas of Difficulty<\/legend><ul id=\"wpforms-898-field_12\"><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-898-field_12_3\" name=\"wpforms[fields][12][]\" value=\"Cervical - Neck\" aria-errormessage=\"wpforms-898-field_12_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-898-field_12_3\">Cervical - Neck<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-898-field_12_4\" name=\"wpforms[fields][12][]\" value=\"Other\" aria-errormessage=\"wpforms-898-field_12_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-898-field_12_4\">Other<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-898-field_13-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"13\"><fieldset><legend class=\"wpforms-field-label\">Has patient had spine surgery?<\/legend><ul id=\"wpforms-898-field_13\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-898-field_13_1\" name=\"wpforms[fields][13][]\" value=\"Yes\" aria-errormessage=\"wpforms-898-field_13_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-898-field_13_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-898-field_13_2\" name=\"wpforms[fields][13][]\" value=\"No\" aria-errormessage=\"wpforms-898-field_13_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-898-field_13_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-898-field_14-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"14\"><label class=\"wpforms-field-label\" for=\"wpforms-898-field_14\">What was done? When was it? Who was the surgeon?<\/label><textarea id=\"wpforms-898-field_14\" class=\"wpforms-field-small\" name=\"wpforms[fields][14]\" aria-errormessage=\"wpforms-898-field_14-error\" ><\/textarea><\/div><div id=\"wpforms-898-field_51-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"51\"><fieldset><legend class=\"wpforms-field-label\">Any bowel, bladder or sexual difficulty?<\/legend><ul id=\"wpforms-898-field_51\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-898-field_51_1\" name=\"wpforms[fields][51][]\" value=\"Yes\" aria-errormessage=\"wpforms-898-field_51_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-898-field_51_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-898-field_51_2\" name=\"wpforms[fields][51][]\" value=\"No\" aria-errormessage=\"wpforms-898-field_51_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-898-field_51_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-898-field_52-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"52\"><label class=\"wpforms-field-label\" for=\"wpforms-898-field_52\">If Yes, please describe below<\/label><textarea id=\"wpforms-898-field_52\" class=\"wpforms-field-small\" name=\"wpforms[fields][52]\" aria-errormessage=\"wpforms-898-field_52-error\" ><\/textarea><\/div><div id=\"wpforms-898-field_53-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"53\"><fieldset><legend class=\"wpforms-field-label\">Do you need any assistance to walk (cane, crutch, wheelchair)?<\/legend><ul id=\"wpforms-898-field_53\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-898-field_53_1\" name=\"wpforms[fields][53][]\" value=\"Yes\" aria-errormessage=\"wpforms-898-field_53_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-898-field_53_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-898-field_53_2\" name=\"wpforms[fields][53][]\" value=\"No\" aria-errormessage=\"wpforms-898-field_53_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-898-field_53_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-898-field_54-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"54\"><label class=\"wpforms-field-label\" for=\"wpforms-898-field_54\">If Yes, please describe below<\/label><textarea id=\"wpforms-898-field_54\" class=\"wpforms-field-small\" name=\"wpforms[fields][54]\" aria-errormessage=\"wpforms-898-field_54-error\" ><\/textarea><\/div><div id=\"wpforms-898-field_20-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"20\"><label class=\"wpforms-field-label\" for=\"wpforms-898-field_20\">Patient&#039;s Date of Birth (MM\/DD\/YYYY)<\/label><input type=\"text\" id=\"wpforms-898-field_20\" class=\"wpforms-field-medium\" name=\"wpforms[fields][20]\" aria-errormessage=\"wpforms-898-field_20-error\" ><\/div><div id=\"wpforms-898-field_21-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"21\"><label class=\"wpforms-field-label\" for=\"wpforms-898-field_21\"> Patient&#039;s Sex<\/label><input type=\"text\" id=\"wpforms-898-field_21\" class=\"wpforms-field-medium\" name=\"wpforms[fields][21]\" aria-errormessage=\"wpforms-898-field_21-error\" ><\/div><div id=\"wpforms-898-field_42-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"42\"><label class=\"wpforms-field-label\" for=\"wpforms-898-field_42\">Height<\/label><input type=\"text\" id=\"wpforms-898-field_42\" class=\"wpforms-field-medium\" name=\"wpforms[fields][42]\" aria-errormessage=\"wpforms-898-field_42-error\" ><\/div><div id=\"wpforms-898-field_43-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"43\"><label class=\"wpforms-field-label\" for=\"wpforms-898-field_43\">Weight<\/label><input type=\"text\" id=\"wpforms-898-field_43\" class=\"wpforms-field-medium\" name=\"wpforms[fields][43]\" aria-errormessage=\"wpforms-898-field_43-error\" ><\/div><div id=\"wpforms-898-field_22-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"22\"><label class=\"wpforms-field-label\" for=\"wpforms-898-field_22\">Do you have neck pain, arm pain, numbness, weakness?<\/label><textarea id=\"wpforms-898-field_22\" class=\"wpforms-field-medium\" name=\"wpforms[fields][22]\" aria-errormessage=\"wpforms-898-field_22-error\" ><\/textarea><\/div><div id=\"wpforms-898-field_23-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"23\"><label class=\"wpforms-field-label\" for=\"wpforms-898-field_23\">Describe patient&#039;s problem. Exactly where? <\/label><textarea id=\"wpforms-898-field_23\" class=\"wpforms-field-medium\" name=\"wpforms[fields][23]\" aria-errormessage=\"wpforms-898-field_23-error\" ><\/textarea><\/div><div id=\"wpforms-898-field_24-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"24\"><label class=\"wpforms-field-label\" for=\"wpforms-898-field_24\">The problem started when?<\/label><input type=\"text\" id=\"wpforms-898-field_24\" class=\"wpforms-field-medium\" name=\"wpforms[fields][24]\" aria-errormessage=\"wpforms-898-field_24-error\" ><\/div><div id=\"wpforms-898-field_25-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"25\"><fieldset><legend class=\"wpforms-field-label\">Have you had chiropractic treatments?<\/legend><ul id=\"wpforms-898-field_25\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-898-field_25_1\" name=\"wpforms[fields][25][]\" value=\"Yes\" aria-errormessage=\"wpforms-898-field_25_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-898-field_25_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-898-field_25_2\" name=\"wpforms[fields][25][]\" value=\"No\" aria-errormessage=\"wpforms-898-field_25_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-898-field_25_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-898-field_26-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"26\"><label class=\"wpforms-field-label\" for=\"wpforms-898-field_26\">Has patient seen a surgeon for a present problem? What was recommended?<\/label><textarea id=\"wpforms-898-field_26\" class=\"wpforms-field-small\" name=\"wpforms[fields][26]\" aria-errormessage=\"wpforms-898-field_26-error\" ><\/textarea><\/div><div id=\"wpforms-898-field_27-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"27\"><label class=\"wpforms-field-label\" for=\"wpforms-898-field_27\">What tests and treatment has patient had?<\/label><textarea id=\"wpforms-898-field_27\" class=\"wpforms-field-small\" name=\"wpforms[fields][27]\" aria-errormessage=\"wpforms-898-field_27-error\" ><\/textarea><\/div><div id=\"wpforms-898-field_28-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"28\"><label class=\"wpforms-field-label\" for=\"wpforms-898-field_28\">Where and when did you have your latest MRI scan?<\/label><textarea id=\"wpforms-898-field_28\" class=\"wpforms-field-small\" name=\"wpforms[fields][28]\" aria-errormessage=\"wpforms-898-field_28-error\" ><\/textarea><\/div><div id=\"wpforms-898-field_29-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"29\"><fieldset><legend class=\"wpforms-field-label\">Are you going to have your MRI scan report faxed to our national receiving fax at 310-659-8869?<\/legend><ul id=\"wpforms-898-field_29\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-898-field_29_1\" name=\"wpforms[fields][29][]\" value=\"Yes\" aria-errormessage=\"wpforms-898-field_29_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-898-field_29_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-898-field_29_2\" name=\"wpforms[fields][29][]\" value=\"No\" aria-errormessage=\"wpforms-898-field_29_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-898-field_29_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-898-field_30-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"30\"><label class=\"wpforms-field-label\" for=\"wpforms-898-field_30\">Describe your recent sport activities before your spine problem:<\/label><textarea id=\"wpforms-898-field_30\" class=\"wpforms-field-small\" name=\"wpforms[fields][30]\" aria-errormessage=\"wpforms-898-field_30-error\" ><\/textarea><\/div><div id=\"wpforms-898-field_31-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"31\"><label class=\"wpforms-field-label\" for=\"wpforms-898-field_31\"> Are you able to do any sport activity now? Describe:<\/label><textarea id=\"wpforms-898-field_31\" class=\"wpforms-field-small\" name=\"wpforms[fields][31]\" aria-errormessage=\"wpforms-898-field_31-error\" ><\/textarea><\/div><div id=\"wpforms-898-field_32-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"32\"><fieldset><legend class=\"wpforms-field-label\"> Do you or did you stress your neck in your work?<\/legend><ul id=\"wpforms-898-field_32\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-898-field_32_1\" name=\"wpforms[fields][32][]\" value=\"Yes\" aria-errormessage=\"wpforms-898-field_32_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-898-field_32_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-898-field_32_2\" name=\"wpforms[fields][32][]\" value=\"No\" aria-errormessage=\"wpforms-898-field_32_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-898-field_32_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-898-field_33-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"33\"><label class=\"wpforms-field-label\" for=\"wpforms-898-field_33\">Describe your work?<\/label><textarea id=\"wpforms-898-field_33\" class=\"wpforms-field-small\" name=\"wpforms[fields][33]\" aria-errormessage=\"wpforms-898-field_33-error\" ><\/textarea><\/div><div id=\"wpforms-898-field_34-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"34\"><label class=\"wpforms-field-label\" for=\"wpforms-898-field_34\">Job Title now (or when you were working)<\/label><input type=\"text\" id=\"wpforms-898-field_34\" class=\"wpforms-field-medium\" name=\"wpforms[fields][34]\" aria-errormessage=\"wpforms-898-field_34-error\" ><\/div><div id=\"wpforms-898-field_35-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"35\"><label class=\"wpforms-field-label\" for=\"wpforms-898-field_35\">Where did you hear about us<\/label><select id=\"wpforms-898-field_35\" class=\"wpforms-field-medium\" name=\"wpforms[fields][35]\"><option value=\"Select One\" >Select One<\/option><option value=\"Vancouver Sun\" >Vancouver Sun<\/option><option value=\"Google_Search\" >Google_Search<\/option><option value=\"NY_Times\" >NY_Times<\/option><option value=\"Bing_Search\" >Bing_Search<\/option><option value=\"Twitter, now X\" >Twitter, now X<\/option><option value=\"Patient_Referral\" >Patient_Referral<\/option><option value=\"Youtube\" >Youtube<\/option><option value=\"Yahoo_Search\" >Yahoo_Search<\/option><option value=\"Other\" >Other<\/option><\/select><\/div><div id=\"wpforms-898-field_36-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"36\"><label class=\"wpforms-field-label\" for=\"wpforms-898-field_36\">What would you like to ask us?<\/label><textarea id=\"wpforms-898-field_36\" class=\"wpforms-field-medium\" name=\"wpforms[fields][36]\" aria-errormessage=\"wpforms-898-field_36-error\" aria-describedby=\"wpforms-898-field_36-description\" ><\/textarea><div id=\"wpforms-898-field_36-description\" class=\"wpforms-field-description\">Please write down what you're curious about and what you'd like to ask here if possible, as it will be a great help for us to know what kind of assistance you need.<\/div><\/div><div id=\"wpforms-898-field_57-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"57\"><label class=\"wpforms-field-label\" for=\"wpforms-898-field_57\">Are you taking any medication for weight loss or diabetes? Please list:<\/label><textarea id=\"wpforms-898-field_57\" class=\"wpforms-field-medium\" name=\"wpforms[fields][57]\" aria-errormessage=\"wpforms-898-field_57-error\" ><\/textarea><\/div><div id=\"wpforms-898-field_49-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"49\"><label class=\"wpforms-field-label\" for=\"wpforms-898-field_49\">What medication are you taking and how often?<\/label><textarea id=\"wpforms-898-field_49\" class=\"wpforms-field-medium\" name=\"wpforms[fields][49]\" aria-errormessage=\"wpforms-898-field_49-error\" ><\/textarea><\/div><div id=\"wpforms-898-field_56-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"56\"><label class=\"wpforms-field-label\" for=\"wpforms-898-field_56\">If you are on anti-coagulant medication, please tell us how long you have taken it and if  you have stopped it to have a procedure in the past<\/label><textarea id=\"wpforms-898-field_56\" class=\"wpforms-field-medium\" name=\"wpforms[fields][56]\" aria-errormessage=\"wpforms-898-field_56-error\" ><\/textarea><\/div><div id=\"wpforms-898-field_37-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"37\"><label class=\"wpforms-field-label\" for=\"wpforms-898-field_37\">If you have a google account, enter your google email address<\/label><input type=\"text\" id=\"wpforms-898-field_37\" class=\"wpforms-field-medium\" name=\"wpforms[fields][37]\" aria-errormessage=\"wpforms-898-field_37-error\" ><\/div><div id=\"wpforms-898-field_38-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"38\"><label class=\"wpforms-field-label\" for=\"wpforms-898-field_38\">Insurance Company Name<\/label><input type=\"text\" id=\"wpforms-898-field_38\" class=\"wpforms-field-medium\" name=\"wpforms[fields][38]\" aria-errormessage=\"wpforms-898-field_38-error\" ><\/div><div id=\"wpforms-898-field_39-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"39\"><label class=\"wpforms-field-label\" for=\"wpforms-898-field_39\">Insurance Type<\/label><select id=\"wpforms-898-field_39\" class=\"wpforms-field-medium\" name=\"wpforms[fields][39]\"><option value=\"Select One\" >Select One<\/option><option value=\"PPO\" >PPO<\/option><option value=\"POS\" >POS<\/option><option value=\"HMO\" >HMO<\/option><option value=\"Medicare\" >Medicare<\/option><option value=\"Auto Insurance\" >Auto Insurance<\/option><option value=\"Affordable Cared Act\" >Affordable Cared Act<\/option><option value=\"Other\" >Other<\/option><option value=\"No Insurance\" >No Insurance<\/option><\/select><\/div><div id=\"wpforms-898-field_48-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"48\"><fieldset><legend class=\"wpforms-field-label\">CONSENT (REQUIRED) <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-898-field_48\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-898-field_48_1\" name=\"wpforms[fields][48][]\" value=\"By submitting this form, I give consent for the Back Institute to share my medical records with outside experts to get additional opinion and for them to contact me.\" aria-errormessage=\"wpforms-898-field_48_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-898-field_48_1\">By submitting this form, I give consent for the Back Institute to share my medical records with outside experts to get additional opinion and for them to contact me.<\/label><\/li><\/ul><\/fieldset><\/div><\/div><!-- .wpforms-field-container --><div class=\"wpforms-recaptcha-container wpforms-is-turnstile\" ><div class=\"g-recaptcha\" data-sitekey=\"0x4AAAAAAA46PA4zgQX4dSas\" data-action=\"FormID-898\"><\/div><input type=\"text\" name=\"g-recaptcha-hidden\" class=\"wpforms-recaptcha-hidden\" style=\"position:absolute!important;clip:rect(0,0,0,0)!important;height:1px!important;width:1px!important;border:0!important;overflow:hidden!important;padding:0!important;margin:0!important;\" data-rule-turnstile=\"1\"><\/div><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"898\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"https:\/\/backinstituteneurosurgery.com\/main\/wp-json\/wp\/v2\/pages\/680\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-898\" class=\"wpforms-submit\" data-alt-text=\"Sending...\" data-submit-text=\"Submit\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit<\/button><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/backinstituteneurosurgery.com\/main\/wp-content\/plugins\/wpforms\/assets\/images\/submit-spin.svg\" class=\"wpforms-submit-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><\/div><\/form><\/div>  <!-- .wpforms-container -->\n<p><strong>Unable To Submit Form? <\/strong> Please try this <a href=\"https:\/\/backinstituteneurosurgery.com\/m\/questionc.html\">simple form<\/a><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Initial Inquiry Form This is a CONFIDENTIAL questionnaire to help us determine the best treatment plan for you. Please fill out this questionnaire At this time, our practice is not affiliated with a trial. Unable To Submit Form? 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