P.R.I.S.M. New Patient Request Form
Welcome to P.R.I.S.M. Spine and Joint! We have expanded our services, and we want to be sure we continue to serve your needs. Our team now includes Sports Medicine, Musculoskeletal Preventive Medicine, Pain Management, Connective Tissue Disorder consultation, MCAS and Dysautonomia/POTS Care, Regenerative Medicine Injections with Ultrasound-guided diagnosis (prolotherapy and PRP), Accupuncture, and more! Please start by providing some basic demographic information below. We look forward to meeting you and being part of your healing journey! Sincerely, Dr. Zingman and the PRISM Team
Background Information
Medical Information
The primary purpose of my visit is to:
Are you an athlete?
MCAS (Mast Cell Activation Syndrome) Care
Dysautonomia Care (including POTS: Postural Orthostatic Tachycardia Syndrome)
Digestive Issues/Abdominal Pain
I am looking for medical pain management care
I am looking for regenerative medicine care (Prolotherapy, PRP, etc. - useful for joint subluxations)
What is your current level of function?
Are you interested in any of the following? Please check all that apply
Treatment Preferences
What are your treatment preferences for PT/rehabilitation?
Additional Questions
If we have a cancellation, how much advance notice do you need if an appointment opens up? (select one)
Are you interested in group programming (such as virtual events) with PRISM staff? (select all that interest you)
Are you interested in being contacted for research studies as a potential research study participant?
Are you a Physician colleague of Dr. Zingman?*
Financial Terms
I understand that PRISM is out-of-network with all insurance companies and that I will be responsible for payment in full on the date of service.*
I understand that if I cancel an appointment within 24 business hours of appointment, the full fee will be charged. Cancellation 25-48 business hours prior to appointment: 50% fee will be charged.*