You can tell us more about your back and neck symptoms by filling out the new patient paperwork. Please contact us if you have questions or wish to schedule an appointment.
Please click here to download a new patient paperwork.
Print out the new patient paperwork and fill out the information. Bring it with you on your first visit to the doctor’s office.
Texas Spine & Neurosurgery specializes in the surgical treatment of disorders of the spine, brain and peripheral nerves. Help us personalize your care under Dr. Zielinski by filling out the file linked above.
The file linked above will contain the following information:
- Satellite Clinic locations of Texas Spine and Neurosurgery
- Patient information including demographic info, emergency contact, primary care physician, etc.
- Conservative treatments that you have tried
- Pain diagram
- Neurosurgical history
- Pain diagram
- chief complaints
- Review of body systems
- allergies and medication
- Pharmacy
- Medical History
- Social History including tobacco and alcohol use
- Surgical history
- Authorization to discuss medical information
- assignment of benefits
- Acknowledgement of receipt of privacy notice
- Acknowledgement of receipt of financial policy
- and Patient web portal release of liability
Important parts of the New Patient Paperwork you need to answer
Pain Diagram
Please mark the image of the body on the left side with the type of pain and its corresponding logo, in accordance with your symptoms, to give us a better image on what your symptoms feel like and where it is located in the body.
Conservative Treatment
Please note the conservative therapies you have tried, how long you have tried, when you last tried, whether it was helpful or not and for which area of the body. This is to make sure we can document accurately which therapies you have tried which will help us guide you in the decision whether to have surgery or not.
