Drisko Fee and Parkins Orthopedic Surgery

The Midwest's premier orthopedic group

North Kansas City Office 2790 North Clay Edwards Drive, Suite 600 • North Kansas City, MO 64116 • (816) 561-3003
Centerpoint Medical Center 19550 E. 39th Street, Suite 410 • Independence, MO 64057 • (816) 303-2400

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APPOINTMENT REQUEST FORM

To schedule an appointment at Drisko, Fee, and Parkins, P.C.from the web, please complete the form below and our scheduling staff will contact you (by phone or e-mail) to confirm your appointment. Please fill out the following information as completely as possible: *required field

Name:*

Address:

City/State/Zip:

Phone*

Email*

Type of Injury:

Date of
Accident / Injury:

mm/dd/yyyy

Injury Info:

If auto accident:
Auto Insurance Co.:
Agent/Contact:
Phone Number:
If injury at work:
Employer:
Employer Contact:
Phone Number:
Work Comp Carrier:
Work Comp Contact:
Phone Number:

Description:

Please Describe (Briefly) Your Orthopaedic Problem:

Referring Physician:

Insurance Plan:

Physician Preference:

Location Preference:

Appt. Time Preference:

Contact By:

Phone:

Yes No (9:00 am to 8:30 pm)

Email:

Yes No

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All information is intended for your general knowledge only and is not a substitute for medical advice or treatment for specific medical conditions.
Use of this online service is subject to the attached disclaimer.