New Patient Appointment Request Your Name (the patient's name)(Required) First Last Your Phone Number(Required)Your Email Address Enter Email Confirm Email Referring Doctor (if applicable)(Required)If you do not have a referral from another doctor, please answer with “None” What is the reason for your visit?(Required)Please choose from one of the following three options. If you’re interested in something other than what’s listed here, please use the “Other” field and let us know what you’re inquiring about. Schedule an appointment as a new patient Schedule a troubleshooting appointment for my DBS device Discuss Botox treatment for Bruxism Other What is the name of your health insurance?(Required)Please list your insurance or put “None” if you do not have insurance. How did you hear about Neurology Solutions?(Required) Doctor’s referral From a Neurology Solutions staff member From a friend From your insurance provider From the internet From a Neurology Solutions patient From a support group Unknown Other If applicable, what is the name of the Neurology Solutions staff member who referred you? If applicable, what is the name of the Neurology Solutions patient who referred you?
