New Patients

Download and fill out the pdf forms. After filling out the required information, save the file and send to our clinic via mail, fax (651.430.3827), or email ([email protected]).

Please note that most general email is not encrypted, and therefore, it is possible for unauthorized individuals to intercept email message. Midwest Spine & Brain Institute is not responsible for the privacy of information transmitted to/from the email address “[email protected]”. Midwest Spine & Brain Institute provides a patient portal to communicate in a secure manner.

All New Patients: Please complete each of the following forms:

If your Appointment is for Back Pain (middle or lower), please also complete the following forms:

Or, If your Appointment is for Neck Pain, please also complete the following forms:

If your Appointment is for a brain condition, please also complete the following form:

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