Appointment Checklist

Please bring the following items with to your first appointment:

• Current Insurance Card
• Copay or Required Downpayment
• Photo ID
• Current Medication List
• List of Known Allergies
• Spine & Pain Centers of Nebraska Evaluation Form (click form and print)
• Spine & Pain Centers of Nebraska Patient Information Form (click form and print)
• Medical Records
• Referring Physician’s Notes
• MRI’s
• CT Scans
• Nerve Conduction Studies
• Worker’s Compensation Form if Applicable

Note:  Without the information from previous providers it may become necessary to reschedule your appointment to a later date.