Physician Referral Service - Request an Appointment - Get Back in the Game

Please complete this form if you would like our Physician Referral Service to call you to help you schedule an appointment with the appropriate HSS physician. Our Physician Referral Service will typically respond within one business day.

You can also speak to our Physician Referral Service by calling +1.877.606.1555 (Monday-Friday 9am-5pm ET).

Required fields in bold.

Tell us who you are

I am a:




How did you hear about HSS?:

Contact Information

Daytime Telephone:


Email Address:


Mailing Address:




State / Province:


Zip Code:



Patient Information

Has the patient had an evaluation or diagnostic testing within the last 6 months?:

Yes No

Has a physician told the patient that surgery is needed?:

Yes No

Date of Birth:




Area/Location of Condition:


Patient's Insurance Plan:


Other Insurance:


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