Home About Medical Staff Services For Patients For Physicians Learning Center News Contact For Physicians Request for Patient Services To refer a patient please fill in the form below and click the Submit Referral button when finished. Note that fields marked with a * are required fields. If you prefer to make a referral over the phone, call us at (920) 882-8200 or toll-free at (888) 231-5236. Location*:  Appleton Oshkosh Physician requesting services*:   Telephone*:   Please check* requested specialty and then choose physician preference, if any. Physiatry   -Choose a Physiatry Doctor- Douglas J. Hendricks, M.D. John P. Revord, M.D. Randall J. Schultz, M.D. J. Talbot Sellers, DO Richard A. Staehler, M.D. Surgery   -Choose a Surgical Doctor- Karl A. Greene, M.D., PhD., FACS Thomas M. Wascher, M.D., FACS David D. DeWitt, M.D. Peter F. Ullrich, Jr., M.D. Are you interested in having surgery?*  Yes No Please indicate* service requested: Advice or opinion requested; return patient with report and assume management for this specific problem. Advice or opinion requested; return patient with report and make recommendations for management for this specific problem. Assume responsibility for the patient's complete care in advance, no report will be sent. Patient information: First Name*:  M.I.: Last Name*: Street*: City*: State*: ZIP*: Date of Birth*:  Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 28 29 30 31 Year 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900  Gender*: Male Female SS#*:  - - Home Phone*:   Daytime Phone*:  Primary Care Physician*:   Work related injury?*:  Yes No   Date of injury: Auto accident?*:  Yes No   Date of accident: Primary Insurance*:  Secondary Insurance To assist in scheduling appointments promptly, please complete the information in the boxes below. Patient symptoms? How long have these symptoms existed? Which treatments have been tried by the patient? (check all that apply) Chiropractic Physical therapy Injections Medications Has the patient had previous back or neck injury? What diagnostic tests has the patient received? X-ray MRI MRA CT EMG Bone Scan       HOME  |  ABOUT  |  MEDICAL STAFF  |  SERVICES  |  FOR PATIENTS  |  FOR PHYSICIANS  |  LEARNING CENTER  |  NEWS  |  CONTACT 5320 West Michaels Drive   |   Appleton, WI 54913-8400   |   Phone: (920) 882-8200 or (888) 231-5236   |   Fax: (920) 882-8210 © 2010 NeuroSpine Center of Wisconsin. All Rights Reserved.