Contact Contact Orthopaedic and Rehabilitation Specialists of Central Illinois "*" indicates required fields Name* First Last Phone*Email* Age*Were you referred by someone?* Yes No Who were you referred by?* Are you seeking treatment for an accident-related injury?* Yes No Please explain your injury*Which of the following pertains to your injury? Shoulder Knee Neck and Back Joint Physical Therapy Other Which Joint?* Please explain*Please read and agree to the following in order to continue.*In accordance with guidelines suggested by the American Medical Association, please acknowledge the following when communicating by email with any physician: 1. This form should be utilized to request a phone call or appointment. It will not be used for medical advice. 2. DO NOT use this form for any emergencies. Emergencies should be handled by calling “911." 3. This form is delivered to our office via E-mail. Please DO NOT send sensitive medical information via this form. 4. Security of email messages is limited by your server, computer, software, browser, and access to your system. Security is appropriately controlled on our website and email system. 5. Email is not a substitute for an office visit and/or physical examination. It is only a convenient means of introduction and to provide us with your contact information in order to speak with you directly and schedule an appointment, if appropriate. 6. Copies of your email correspondence may be kept in your chart. 7. Please understand that we may not answer your E-mail directly and that communication may be via telephone. 8. Please provide an accurate phone number. I agree to the above stipulations. CAPTCHACommentsThis field is for validation purposes and should be left unchanged. Δ Forms New Patient Form Orthopaedic & Rehabilitation Specialists of Central Illinois 2773 North Main Street Decatur, Illinois 62526 217-877-2088