Shepherd Pain Institute
2020 Peachtree Rd, NW
Atlanta, GA 30309
Phone: 404-355-1144
Fax: 404-355-6980
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Appointment Request

This service is ONLY FOR NON-URGENT appointment requests. If the patient has an urgent request, please call 911.

   * Required Fields
Appointment Service Options:*
 
Request Provider (optional)
Dr. Bert Blackwell
Dr. Erik Shaw
Dr. Urzula Klich, Ph. D.
 
Request for Information
The Requestor may be the patient's relative, caregiver or friend.
First Name: *
Last Name: *
 
Patient Information
Same as Above
First Name: *
Last Name: *
 
Patient Phone Numbers:
SPI will use these patient numbers to confirm the appointment request:
Patient preferred number: *
Patient preferred alternate number:
Patient preferred email address:
 
Patient Type: *
 
Requested Date:
First Available
Or
Preferred Date Click Here to Pick up the date
 
Preferred Time(s):
Any Time
Early AM
Late AM
Early PM
Late PM
 
Patient Health Insurance *
Other Insurance:
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