For Patients

Welcome to Southern California Brain & Spine Surgery You can either fill out the from below online or Click HERE, print it out, and bring the completed forms to your appointment.

Preparing For Your Appointment Checklist

We want to make sure you get the most out of your appointment. Having the following information at your appointment is important so that we have all the correct information to identify, understand, and treat your spinal and/or brain condition.

Please read over the below checklist and bring each item with you to your appointment

  • Drivers License or Other Form of Photo Identification
  • Insurance Cards
  • Completed Patient Form
  • All Radiology Studies Pertaining to your Case

Along with the report, please bring the CD or actual scan

  • MRI Scans
  • CT Scans
  • X-Rays

Prior Medical Reports

  • Operative and Radiology Reports
  • Injection History
  • EMG and Nerve Conduction Results
  • Consultations from Other and/or Referring Physicians

Information of ALL Physicians Involved in Your Care (Including your PCP)

  • First and Last Name
  • Contact Telephone Number
  • Address

Patient Questionnare

    1

    Personal
    Information

    2

    Chief complain
    & symptoms

    3

    Previous
    history

    4

    Health
    questions

    5

    Symptoms
    of conditions

    6

    Patient
    Information

    7

    Office
    Refencence

    8

    Primary/ Secondary
    insurance

    Personal information

    Chief complain & symptoms

    Previous history

    Health questions

    Symptoms of conditions











    Patient Information Sheet/Datos del paciente

    Please provide complete information so that we may bill your insurance. / Por favor provea información completa para poder enviar el cobro a la empresa de seguros.

    Office Reference

    Primary Insurance / Seguro Primario

    Secondary Insurance / Seguro Secundario

    I certify that the above information is true and accurate. / Certifico que toda la información provista es verdadera y correcta.