Please complete the following information as thoroughly as possible to request an appointment with Dr. Rodgers. We will review your request and a member of our staff will contact you as soon as possible to set up an appointment at your convenience.   Name: Address: City: State:      Zip Code:  Country: Phone: E-mail:   Yes No I have previously been seen by Dr. Rodgers. Yes No  Please schedule me for the first available appointment. Yes No I am being referred to Tulsa NeuroSpine by my primary care physician. Please list your physician's name and telephone number: AMCARE Aetna Blue Cross/Blue Shield CHAMPVA Cigna Commercial Insurance HealthChoice Medicare Preferred Community Choice PPO Oklahoma Pacificare of Oklahoma - Springer Physician's Liability (PLICO) Springer HMO United Healthcare Work Comp Not Listed Please indicate which insurance you carry. If you do not see your insurance listed, please select "Not Listed." Briefly describe the condition for which you are requesting to be seen. Also, please list any reports or test results regarding this condition that may be available and where they may be obtained. Please list any other information you feel would helpful for us to know prior to your visit.