LinkedInThis field is for validation purposes and should be left unchanged. Complete the form below to request an appointment. A member of our scheduling team will contact you to confirm availability and finalize your appointment. Prefer to schedule by phone? Call Midwest Sports Medicine at (877) 945-9090. Patient InformationAre you a new or returning patient?(Required) New Patient Returning Patient Name(Required) First Last Email(Required) Phone(Required)Preferred Contact Method Phone Call Text Message Email Reason for VisitBody Area or Reason for Visit(Required) Hip Knee Shoulder Elbow Hand or Wrist Foot or Ankle Back or Spine Sports Injury Joint Pain Other Select all that apply.Brief Description of Your ConcernPlease briefly describe the area of concern, injury, or pain. Do not include confidential medical records or detailed medical history.Preferred ProviderFirst Available ProviderDr. Eugene LopezDr. Mary MorrellDr. Bruce MontellaDr. Sean OdellDr. Thomas A. McNally, MDRoss Robarts, PA-CJoseph Tayani, PA-CLoren Versheldon, PA-CInsurance InformationIs this appointment related to a work injury or workers’ compensation claim?(Required) Yes No Not Sure Primary Insurance ProviderDo You Have Secondary Insurance? Yes No Secondary Insurance ProviderScheduling PreferencesFirst Choice Date(Required) MM slash DD slash YYYY Second Choice Date MM slash DD slash YYYY Preferred Time(Required)Select a preferred timeMorningAfternoonNo PreferencePlease note: Submitting this form does not confirm an appointment. A member of our scheduling team will contact you to verify availability and finalize your appointment. Please provide only the information needed to schedule your visit. If you are experiencing a medical emergency, call 911 or visit the nearest emergency room.Appointment Request Acknowledgment(Required) I understand that this is an appointment request and does not confirm an appointment.
