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

List of Questions and Concerns

Patient Medical History
Chief Complaint
Please Explain Your Symptoms
Previous Surgeries (Include the year the surgery was completed)
Previous Medical / Illness (Check all that apply)
Diseases That Applies To Anyone In Your Immediate Family
Medications
Allergies
Health Questions

Do you smoke?

If yes, how many cigarettes

Do you drink alcohol?

If yes, how many drinks

Do you use intravenous drugs?

Which hand is your dominant hand?

What is your occupation?

How long have you been doing this job?

Do you live alone?

YesNo

Who do you live with?

Symptoms That Best Describe Your Conditions (Check all that apply)
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.

Who referred you to our office?/¿Quién le remitió a esta oficina?
Primary Insurance / Seguro Primario
Secondary Insurance / Seguro Secundario

Please give all insurance cards and forms to the receptionist to be copied. / Le agradeceremos le entregue todos los formularios y tarjetas del seguro a la recepcionista, para que le saque copias.

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