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
Full Name*
Phone
Email*
Date of Birth*
Current age (numerals only please)*
City
State/Province*
Alabama
Alaska
Arizona
Arkansas
American Samoa
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Virgin Islands
Washington
West Virginia
Wisconsin
Wyoming
outside of the U.S.A.
British Columbia, Canada
Massachusetts
North Carolina
South Carolina
DC
MD
VA
va
Md
Medical Information
The primary purpose of my visit is to:
Be evaluated for Ehlers-Danlos Syndrome
Seeking Ehlers-Danlos Syndrome care
I am a hypermobile athlete with an injury/in need of pain management
Sports Medicine and/or Regenerative Medicine
Seeking care for another musculoskeletal condition
Pelvic floor or musculoskeletal pregnancy care
Are you an athlete?
No, I am not an athlete.
Yes, and I am seeking care for a musculoskeletal injury or pain
Yes, I have relative energy deficiency of sport (RED-S)
Yes, I am seeking dance medicine or care for a dance injury
MCAS (Mast Cell Activation Syndrome) Care
I already have MCAS Diagnosis
I would like to be evaluated for MCAS
Unsure
N/A
Dysautonomia Care (including POTS: Postural Orthostatic Tachycardia Syndrome)
I already have dysautonomia diagnosis
I would like to be evaluated for dysautonomia
Unsure
N/A
Digestive Issues/Abdominal Pain
yes, I have these symptoms
no, I do not have these symptoms
I am looking for medical pain management care
Yes, I am interested in medical pain management
No, I am not interested in medical pain management
Unsure
I am looking for regenerative medicine care (Prolotherapy, PRP, etc. - useful for joint subluxations)
Yes, I am interested in receiving regenerative medicine care
No, I am not interested in receiving regenerative medicine care
Unsure
What is your current level of function?
Mostly bedbound
Able to move freely around my home but not well enough to go grocery shopping
Able to do basic household tasks but unable to work/attend school
Able to work/attend school/do childcare but only part time or with significant accommodations
Able to be out of the home/productive 8 hrs a day
Require assistive device for ambulation outside of the home
Are you interested in any of the following? Please check all that apply
Craniocervical or other spinal Instability care
Low Back Pain/Tethered Cord care
Nutrition Health Coaching
Infusions for hydration and MCAS/POTS
Ketamine Infusions
Psychotherapy
Treatment Preferences
What are your treatment preferences for PT/rehabilitation?
Detailed PT Prescription from Physician (can be provided at initial physician appointment)
Detailed PT Plan including videos and specific exercises (Can be obtained with an initial PT eval and 2 follow-up PT appointments at PRISM)
I am a local patient looking for appointments on an ongoing basis
I am a long distance patient looking for 1-6 weeks of intensive treatment
Additional Questions
How did you hear about us?
Referral from a healthcare provider
Referral from a friend
Via a support group
Media coverage
Web search
If you were referred by a specific physician, please write their full name, specialty, and practice location here:
If we have a cancellation, how much advance notice do you need if an appointment opens up? (select one)
None - I am generally available same day
1-2 days
1 week or more
Are you interested in group programming (such as virtual events) with PRISM staff? (select all that interest you)
Information/Support for Patients (Living with EDS/How to recognize Craniocervical Instability/Mast Cell Activation/etc.)
Information/Support for Family Members/Caregivers (Understanding EDS, etc.)
Group Postural Training/Exercises
Are you interested in being contacted for research studies as a potential research study participant?
yes
no
Are you a Physician colleague of Dr. Zingman?*
yes
no
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.*
Yes, I agree.
No, please remove me from the waitlist.
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.*
Yes, I agree.
No, please remove me from the waitlist.
Submit