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NEW PATIENT / CONSULTATION REQUEST FORM

Dr. Steven B. Ross
Chiropractic Physician • Spinal Biomechanics Consultant
Expert Witness & Medico-Legal Consultant

ABOUT THE PRACTICE

Dr. Ross maintains an active clinical and forensic practice focused on:

  • Spinal and musculoskeletal conditions

  • Motor vehicle collision injuries

  • Injury evaluation and causation analysis

  • Second opinions

  • Complex or unresolved spine-related complaints

  • Independent evaluations and consultation

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Because of the specialized nature of the practice, all requests are reviewed prior to scheduling.

PATIENT INFORMATION

EMERGENCY CONTACT

HOW DID YOU HEAR ABOUT US?
Physician Referral
Existing Patient
Internet Search
LinkedIn
Attorney Referral
Social Media
Other
REASON FOR CONSULTATION
Second Opinion
Injury Evaluation
Neck Pain
Mid-Back Pain
Low Back Pain
Headaches
Sciatica / Radiculopathy
Motor Vehicle Collision Injury
Work Injury
Sports Injury
Joint Pain
Numbness / Tingling
Other
Is This Related To An Accident Or Legal Case?
No
Yes — Motor Vehicle Collision
Yes — Personal Injury Claim
Yes — Workers’ Compensation
Yes — Attorney Involved
Other

IF APPLICABLE:

PRIOR CARE / TREATMENT

Have you previously received treatment for this condition?
Yes
No
DIAGNOSTIC STUDIES AVAILABLE
MRI
CT Scan
X-Rays
EMG / Nerve Testing
Medical Records
Prior Reports
Accident Reports
None Available
PAYMENT INFORMATION
Cash Pay
Credit / Debit Card
Attorney Lien (if accepted)
Other

Please Note:

Dr. Ross does not participate with insurance plans and is not contracted with private insurance carriers, Medicare, or Medi-Cal.


Payment is due at the time of service unless other arrangements have been made in advance.

INFORMED CONSENT / ACKNOWLEDGEMENT

I understand that submitting this form does not guarantee acceptance as a patient and does not establish a doctor-patient relationship until Dr. Ross formally accepts and evaluates me.


I understand that Dr. Ross maintains a selective clinical and consultation-based practice and may decline cases outside his scope.


I understand that chiropractic evaluation and treatment, like all healthcare procedures, involve certain risks, and no guarantees regarding outcome or improvement can be made.


I certify that, to the best of my knowledge, the information provided on this form is accurate and complete.


I authorize Dr. Ross and his staff to communicate with me about scheduling, record requests, and consultation-related matters.

OFFICE POLICIES

  • Payment is due at the time of service.

  • Please provide at least 24 hours’ notice for cancellations or rescheduling.

  • Requests for records or reports may involve additional fees.

  • Complex medico-legal consultations may require review of records prior to scheduling.

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CONTACT INFORMATION

Dr. Steven B. Ross
San Diego, California

Office: 858-544-1494
drross@drstevenross.com
DrStevenRoss.com

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