Get Pain Help - Make an Appointment

Primary Contacts

Telephone:
1 (678) 741-3242

Questions?

Do you have any general questions, or questions specific to billing or scheduling? Fill out our contact form and someone will respond to you as soon as possible. You may also contact our office by phone directly.

Make an appointment

Patient Info

*Patient Name:

*Date of Birth (Month/Day/Year):

Sex:

*Address:

Male

Female

*City:

*State:

*Zip:

*Phone:

Insurance Info

Patients Name:

Insurance Carrier:

Self Pay:

Policy Name Holder:

Date of Birth:

Member ID:

Group Name:

Group Number:

Insurance Co. Phone:

ext:

Workers Comp Insurance Info

WC Insurance Carrier:

Claim #:

Date of Injury (Month/Day/Year):

Claims Phone:

ext:

Adjuster Name:

Adjuster Phone:

ext:

Adjuster Fax:

Adjuster Email:

Case Manager Name:

Case Manager Phone:

ext:

Services Requested

	Back Injury		2nd Opinion
	Neck Injury		EMG / Nerve Conduction
	Knee Injury		IME
	Shoulder Injury		Evaluate and Treat
	Other

Referral

Referring Physician Name:

Referring Physician Phone:

ext:

Referring Physician Address:

City:

State:

Zip:

Miscellaneous

Comments/Additional Information:

We are proud to have patients from Canton, Alpharetta, Roswell, Marietta, Atlanta, Woodstock, Cartersville, Acworth, Ellijay, Hiram, Dallas, Dalton, Suwanee, Gainesville, Jasper, Calhoun, Commerce, Athens, and Cumming.