{"id":1273,"date":"2021-06-28T07:46:28","date_gmt":"2021-06-28T07:46:28","guid":{"rendered":"https:\/\/flspinalsurgeon.com\/?page_id=1273"},"modified":"2023-02-14T18:43:48","modified_gmt":"2023-02-14T18:43:48","slug":"questionnaire","status":"publish","type":"page","link":"https:\/\/flspinalsurgeon.com\/questionnaire\/","title":{"rendered":"Questionnaire"},"content":{"rendered":"

[et_pb_section fb_built=”1″ _builder_version=”4.16″ use_background_color_gradient=”on” background_color_gradient_type=”circular” background_color_gradient_stops=”#1c1c1c 6%|#000064 81%” background_color_gradient_start=”#1c1c1c” background_color_gradient_start_position=”6%” background_color_gradient_end=”#000064″ background_color_gradient_end_position=”81%” custom_margin=”0px|0px|0px|0px|false|false” locked=”off” global_colors_info=”{}”][et_pb_row column_structure=”3_5,2_5″ admin_label=”Row” _builder_version=”4.16″ _module_preset=”default” width=”87%” custom_margin=”|46px||auto||” border_radii=”on|5px|5px|5px|5px” global_colors_info=”{}”][et_pb_column type=”3_5″ _builder_version=”4.16″ _module_preset=”default” global_colors_info=”{}”][et_pb_image src=”https:\/\/flspinalsurgeon.com\/wp-content\/uploads\/2021\/12\/american-access-to-spine-5.jpg” title_text=”american-access-to-spine-5″ align=”center” force_fullwidth=”on” _builder_version=”4.16″ _module_preset=”default” border_radii=”on|5px|5px|5px|5px” global_colors_info=”{}”][\/et_pb_image][\/et_pb_column][et_pb_column type=”2_5″ _builder_version=”4.16″ _module_preset=”default” global_colors_info=”{}”][et_pb_image src=”https:\/\/flspinalsurgeon.com\/wp-content\/uploads\/2021\/03\/AASOCI.png” title_text=”AASOCI” align=”center” _builder_version=”4.16″ _module_preset=”default” custom_margin=”3%||||false|false” global_colors_info=”{}”][\/et_pb_image][\/et_pb_column][\/et_pb_row][\/et_pb_section][et_pb_section fb_built=”1″ _builder_version=”4.16″ _module_preset=”default” custom_margin=”0px||||false|false” custom_padding=”0px||||false|false” global_colors_info=”{}”][et_pb_row column_structure=”1_5,3_5,1_5″ _builder_version=”4.16″ _module_preset=”default” custom_margin=”5%||5%||true|false” global_colors_info=”{}”][et_pb_column type=”1_5″ _builder_version=”4.16″ _module_preset=”default” custom_padding=”0px||||false|false” global_colors_info=”{}”][et_pb_text _builder_version=”4.16″ _module_preset=”default” header_3_text_align=”left” header_3_text_color=”#000000″ header_3_font_size=”2em” header_3_text_align_tablet=”right” header_3_text_align_phone=”left” header_3_text_align_last_edited=”on|phone” locked=”off” global_colors_info=”{}”]<\/p>\n

Get Started:<\/h3>\n

[\/et_pb_text][\/et_pb_column][et_pb_column type=”3_5″ _builder_version=”4.16″ _module_preset=”default” custom_padding=”0px||||false|false” global_colors_info=”{}”][et_pb_text _builder_version=”4.16.0″ _module_preset=”default” text_text_color=”#000000″ text_font_size=”18px” header_text_color=”#000000″ header_font_size=”1.5em” header_line_height=”1.1em” custom_margin=”0px||0px||true|false” hover_enabled=”0″ global_colors_info=”{}” sticky_enabled=”0″]<\/p>\n

Welcome to American Access to Spine’s Application Page<\/h1>\n

 <\/p>\n

Our application has 2 main sections.<\/strong><\/p>\n

1. Please fill in the lifestyle questionnaire blanks and submit the form.<\/p>\n

2. Next, please download the new patient paperwork, fill it out and return it to Angelia.
Her email is: angelia@americanspineortho.com<\/a>.<\/p>\n

It is important that we receive both segments of the application for your application to be considered.<\/p>\n

[\/et_pb_text][\/et_pb_column][et_pb_column type=”1_5″ _builder_version=”4.16″ _module_preset=”default” custom_padding=”0px||||false|false” global_colors_info=”{}”][\/et_pb_column][\/et_pb_row][\/et_pb_section][et_pb_section fb_built=”1″ _builder_version=”4.16″ _module_preset=”default” use_background_color_gradient=”on” background_color_gradient_type=”circular” background_color_gradient_stops=”#1c1c1c 6%|#000064 81%” background_color_gradient_start=”#1c1c1c” background_color_gradient_start_position=”6%” background_color_gradient_end=”#000064″ background_color_gradient_end_position=”81%” custom_margin=”0px|0px|0px|0px|false|false” custom_padding=”||2px|||” global_colors_info=”{}”][et_pb_row column_structure=”1_5,3_5,1_5″ _builder_version=”4.16″ _module_preset=”default” custom_margin=”|auto|34px|auto||” custom_padding=”||7px|||” global_colors_info=”{}”][et_pb_column type=”1_5″ _builder_version=”4.16″ _module_preset=”default” global_colors_info=”{}”][et_pb_text _builder_version=”4.16″ _module_preset=”default” header_3_text_align=”left” header_3_text_color=”#FFFFFF” header_3_font_size=”2em” custom_padding=”|2px||||” header_3_text_align_tablet=”right” header_3_text_align_phone=”left” header_3_text_align_last_edited=”on|phone” global_colors_info=”{}”]<\/p>\n

Step 1:<\/h3>\n

[\/et_pb_text][\/et_pb_column][et_pb_column type=”3_5″ _builder_version=”4.16″ _module_preset=”default” background_color=”RGBA(255,255,255,0)” global_colors_info=”{}”][et_pb_contact_form email=”cassidy@americanspineortho.com” custom_message=”New Application Details:||et_pb_line_break_holder||||et_pb_line_break_holder||Phone – %%Phone%%||et_pb_line_break_holder||Full Name – %%Name%%||et_pb_line_break_holder||Email Address – %%Email%%||et_pb_line_break_holder||Message – %%Message%%||et_pb_line_break_holder||Annual Income – %%Income%%||et_pb_line_break_holder||Number of Dependents (Children) – %%Dependents%%||et_pb_line_break_holder||Current Employment – %%occupation%%||et_pb_line_break_holder||Area of Injury – %%place_of_injury%%||et_pb_line_break_holder||City Currently Residing – %%residence_address%%||et_pb_line_break_holder||What Makes A Good Candidate – %%Candidate%%||et_pb_line_break_holder||Marital Status – %%Marital_Status%%||et_pb_line_break_holder||Field_Service – 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global_colors_info=”{}” button_text_size__hover_enabled=”off” button_one_text_size__hover_enabled=”off” button_two_text_size__hover_enabled=”off” button_text_color__hover_enabled=”off” button_one_text_color__hover_enabled=”off” button_two_text_color__hover_enabled=”off” button_border_width__hover_enabled=”off” button_one_border_width__hover_enabled=”off” button_two_border_width__hover_enabled=”off” button_border_color__hover_enabled=”off” button_one_border_color__hover_enabled=”off” button_two_border_color__hover_enabled=”off” button_border_radius__hover_enabled=”off” button_one_border_radius__hover_enabled=”off” button_two_border_radius__hover_enabled=”off” button_letter_spacing__hover_enabled=”off” button_one_letter_spacing__hover_enabled=”off” button_two_letter_spacing__hover_enabled=”off” button_bg_color__hover_enabled=”off” button_one_bg_color__hover_enabled=”off” button_two_bg_color__hover_enabled=”off”][\/et_pb_contact_field][et_pb_contact_field field_id=”Phone” field_title=”Phone” fullwidth_field=”on” _builder_version=”4.16″ _module_preset=”default” global_colors_info=”{}”][\/et_pb_contact_field][et_pb_contact_field field_id=”Income” field_title=”Annual Income” fullwidth_field=”on” _builder_version=”4.16″ _module_preset=”default” global_colors_info=”{}”][\/et_pb_contact_field][et_pb_contact_field field_id=”Dependents” field_title=”Number of Dependents (Children)” fullwidth_field=”on” _builder_version=”4.16″ _module_preset=”default” global_colors_info=”{}”][\/et_pb_contact_field][et_pb_contact_field field_id=”occupation” field_title=”Current Employment” fullwidth_field=”on” _builder_version=”4.16″ _module_preset=”default” global_colors_info=”{}”][\/et_pb_contact_field][et_pb_contact_field field_id=”place_of_injury” field_title=”Please Specify Area of Injury (Body Part)” fullwidth_field=”on” _builder_version=”4.16″ _module_preset=”default” global_colors_info=”{}”][\/et_pb_contact_field][et_pb_contact_field field_id=”residence_address” 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Please describe in detail why and how this would make a difference for you.” field_type=”text” fullwidth_field=”on” _builder_version=”4.16″ _module_preset=”default” global_colors_info=”{}”][\/et_pb_contact_field][et_pb_contact_field field_id=”Marital_Status” field_title=”Marital Status” field_type=”radio” radio_options=”%91{%22value%22:%22Single%22,%22checked%22:0,%22dragID%22:-1},{%22value%22:%22Married%22,%22checked%22:0,%22dragID%22:0},{%22value%22:%22Divorced%22,%22checked%22:0,%22dragID%22:1},{%22value%22:%22Widowed%22,%22checked%22:0,%22dragID%22:2}%93″ fullwidth_field=”on” _builder_version=”4.16″ _module_preset=”default” form_field_background_color=”rgba(10,0,0,0.32)” form_field_text_color=”#000000″ form_field_font_size=”14px” background_color=”#FFFFFF” background_enable_color=”on” text_orientation=”left” module_alignment=”left” custom_margin=”|||3%|false|false” global_colors_info=”{}”][\/et_pb_contact_field][et_pb_contact_field field_id=”Field_Service” field_title=”Past Service” field_type=”radio” radio_options=”%91{%22value%22:%22Military Service or Veteran%22,%22checked%22:0,%22dragID%22:-1},{%22value%22:%22Law Enforcement%22,%22checked%22:0,%22dragID%22:0},{%22value%22:%22First Responder%22,%22checked%22:0,%22dragID%22:1},{%22value%22:%22N\/A%22,%22checked%22:0,%22dragID%22:2}%93″ fullwidth_field=”on” _builder_version=”4.16″ _module_preset=”default” form_field_background_color=”rgba(10,0,0,0.32)” form_field_text_color=”#000000″ form_field_font_size=”14px” background_color=”#FFFFFF” background_enable_color=”on” text_orientation=”left” module_alignment=”left” custom_margin=”|||3%|false|false” global_colors_info=”{}”][\/et_pb_contact_field][\/et_pb_contact_form][\/et_pb_column][et_pb_column type=”1_5″ _builder_version=”4.16″ _module_preset=”default” global_colors_info=”{}”][\/et_pb_column][\/et_pb_row][\/et_pb_section][et_pb_section fb_built=”1″ _builder_version=”4.16″ _module_preset=”default” global_colors_info=”{}”][et_pb_row column_structure=”1_5,3_5,1_5″ _builder_version=”4.16″ _module_preset=”default” custom_margin=”3%||3%||true|false” global_colors_info=”{}”][et_pb_column type=”1_5″ _builder_version=”4.16″ _module_preset=”default” global_colors_info=”{}”][et_pb_text _builder_version=”4.16″ _module_preset=”default” header_3_text_align=”left” header_3_text_color=”#000000″ header_3_font_size=”2em” header_3_text_align_tablet=”right” header_3_text_align_phone=”left” header_3_text_align_last_edited=”on|phone” locked=”off” global_colors_info=”{}”]<\/p>\n

Step 2:<\/h3>\n

[\/et_pb_text][\/et_pb_column][et_pb_column type=”3_5″ _builder_version=”4.16″ _module_preset=”default” global_colors_info=”{}”][et_pb_text _builder_version=”4.16″ _module_preset=”default” text_text_color=”#000000″ text_font_size=”18px” header_text_color=”#000000″ header_font_size=”1.5em” header_line_height=”1.1em” custom_margin=”0px||6%||false|false” global_colors_info=”{}”]<\/p>\n

New Patient Paperwork<\/h1>\n

As a first time patient, we have made it easy for you by offering forms online. Please select the form, print out and bring them to your appointment already completed.<\/p>\n

By offering you this option to print the form in advance, you will be able to complete at your own pace and in the comfort of your own home. Please print the form on white paper only.<\/p>\n

[\/et_pb_text][et_pb_button button_url=”https:\/\/flspinalsurgeon.com\/wp-content\/uploads\/2021\/04\/blank-new-patient-packet_2.pdf” button_text=”Download Form” button_alignment=”center” _builder_version=”4.16″ _module_preset=”default” custom_button=”on” button_text_color=”#FFFFFF” button_bg_color=”#0C71C3″ button_bg_use_color_gradient=”on” button_bg_color_gradient_stops=”#1d2793 0%|#3b2fe2 100%” button_bg_color_gradient_start=”#1d2793″ button_bg_color_gradient_end=”#3b2fe2″ button_border_width=”0px” button_border_radius=”4px” button_letter_spacing=”0px” button_use_icon=”off” custom_margin=”|25%||25%|false|true” custom_margin_tablet=”|25%||25%|false|true” custom_margin_phone=”|0%||0%|false|true” custom_margin_last_edited=”on|phone” global_colors_info=”{}”][\/et_pb_button][\/et_pb_column][et_pb_column type=”1_5″ _builder_version=”4.16″ _module_preset=”default” global_colors_info=”{}”][\/et_pb_column][\/et_pb_row][\/et_pb_section]<\/p>\n","protected":false},"excerpt":{"rendered":"

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