Please review our terms of use. The information provided on this form is intended solely for appointment and scheduling purposes at the designated location. By selecting this button, you acknowledge your full understanding and consent regarding the purposes of this form. You furthermore acknowledge that all information provided regarding yourself and parties involved is correct and accurate.
Summit Brain, Spine & Orthopedics maintains the right to use this form to schedule appointments. Summit Brain, Spine & Orthopedics protects patient confidentiality as well as any personal or health related information unless express consent or legal obligation is produced. Confidential information includes diagnosis, treatment, medication, personal information, symptoms, and care plans. All information given is done freely and with full knowledge and consent of the patient or legal representative.
This form is not to be used for solicitation of any services. Any contact made for solicitation is in violation of these terms.