New Patient Forms


New Patient Form

This questionnaire should be completed before your initial evaluation and interview with Dr Hepler. For any questions preparing this document please contact our Delray Beach office or our Fort Lauderdale office for further information or instructions.

 

Lumbar Questionaire

This questionnaire should be completed before your surgery and at 3, 6, 12, 24 month follow up visits. For any questions preparing this document please contact our Delray Beach office or our Fort Lauderdale office for further information or instructions.

 

Deformity Questionaire

This questionnaire has been designed to give the doctor information as to how your back trouble (or leg) has affected your ability to manage in everyday life.

 

Cervical Questionaire

This questionnaire has been designed to give the doctor information as to how your ​neck pain​ has affected your ability to manage in everyday life.

 

Patient Financial Responsibility Statement

This document outlines details of the financial responsibility on your part for the medical services you seek with us.

 

Patient Rights Statement

This Notice of Privacy Practices describes how we may use, and disclose, your protected health information (PHI) to carry out treatment, payment, or health care operations (TPO) and for purposes required by law and describes your rights to access and control your protected health information.