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Home Patient Scheduling

New Patient Scheduling

 Location: Referral Type: WC 2nd Treatment WC Primary Treating Physician Surgery Consultation Private Insurance QME AME Personal Injury Other First Name: Last Name: Email: Primary Phone: Cell Phone: Work Phone: Date of Birth: S.S.#: Address: State: Zip Code: City: Insurance Carrier: Address: City: Phone Number: Claim Number: State: Zip Code: Email: WCAB#: Body parts to be treated: Claims Adjuster: Date of Injury: Extension Number: LEGAL INFORMATION INSURANCE INFORMATION Defense Attorney: Address: City: Phone Number: State: Zip Code: Applicant Attorney: Address: City: Phone Number: State: Email: Zip Code: Email: Please advise your patients that the initial visit may take 3 to 4 Hours. This may include the need to obtain detailed history if it has not been performed prior to the office visit. Further testing may be required which will add to the time of the evaluation. Please advise your patients, so we can make their experience in our office pleasurable and comfortable. In order to avoid delay in the office, our historian will call the patient prior to the office visit and obtain detailed history of the patient. Please inform the patient that our office will call them at home and this will require about one hour. If the patient prefers to call the historian, Alma, she can be reached at (818) 481-1812 or (760) 200-3604. Please note that we have Spanish interpreters in the office. If your patient speaks different languages please arrange for the appropriate interpreter or inform us and we will be happy to make this arrangement. Parking is available but we do not Validate. If possible please hand a copy of this document to your patient so that they can be informed about the policies of the office. PLEASE READ BEFORE SUBMITTING: ADDITIONAL INFORMATION: Protection Code:* Please, enter the text shown in the image into the field below. captcha code reload

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