Please enable JavaScript in your browser to complete this form.Patient Name *FirstLastLayoutPatient Phone *Date of AccidentLaw Firm / Attorney Name *AddressAddress Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateLayoutFirm Email Contact *Law Firm PhoneRequested Appointment Date *DateTimeSame Day Appointments available at Southern Regional Medical Center primary care centers and physical therapy centers only. Requested appointment times are subject to availability.Choose a Location *Baton RougeLafayetteShreveportIf you are scheduling an appointment for Orthopedics or MRI, please attach the following documents by uploading them below: MRI: (1) Physician Referral, (2) Signed Approval ORTHO: (1) Past Medical Reports, (2) MRI reports, (3) Signed Approval File Upload Click or drag a file to this area to upload. Submit
