PPO Patient Appointment Request Form
This form is intended to be utilized by NEW PATIENTS
with PPO INSURANCE ONLY.
Other insurance types such as Medicare, Workers Comp, etc. require additional documentation prior to processing the new patient appontment request. DO NOT complete this form unless you have PPO INSURANCE.
Fields with
*
are required
Patient Information
Patient Name
Select title
Ms
Miss
Mrs
Mr
Dr
Best Contact Phone Number
Patient Email
Address
Afghanistan
Albania
Algeria
Andorra
Angola
Anguilla
Antigua & Deps
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia Herzegovina
Botswana
Brazil
British Virgin Islands
Brunei
Bulgaria
Burkina
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Rep
Chad
Chile
China
Colombia
Comoros
Congo
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Faroe Islands
Fiji
Finland
France
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Ivory Coast
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea North
Korea South
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Saint Vincent & the Grenadines
Samoa
San Marino
Sao Tome & Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Sudan
Spain
Sri Lanka
St Kitts & Nevis
St Lucia
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad & Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican
Venezuela
Vietnam
Yemen
Zambia
Zimbabwe
Other
Patient Date of Birth
Sex
Male
Female
Undisclosed
Preferred location
Pleasant Hill
Pleasanton
Corte Madera
Preferred Physician
Ruben Kalra MD
William Longton MD
Richard Shinaman MD
First Available
Primary Care Physician
Referring Physician
PPO Insurance carrier name
PPO Member ID
PPO Group number
Attach image of FRONT of primary insurance card
(This helps us expedite your scheduling)
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Attach image of BACK of primary insurance card
(This helps us expedite your scheduling)
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Are you CURRENTLY being treated by a pain management doctor? If YES, the office needs the last 3 office notes, procedure notes and imaging prior to scheduling
Yes
No
Have you PREVIOUSLY been treated by a pain management doctor? If YES, the office needs a copy of the most recent office notes, procedure notes and imaging prior to scheduling
Yes
No
IF APPLICABLE, either, attach all needed office notes, procedure notes and imaging or have the documents faxed to (925) 287-0913, ATTN.: New Patient Coordinator
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How did you hear about us?
Physician referral
Insurance referral
Yelp
Yelp Ad
Google search
Google Ad
Google Maps
Yahoo search
HealthGrades
WebMD
Magazine or newspaper
Word of mouth
E-mail
other:
Comments
Drug Abuse Diversion: We are passionate about and dedicated to helping our patients overcome their pain. We expect patients to be committed to working with us in order to get better. We will do everything we can to help our patients but we are strongly opposed to any type of drug abuse and diversion. We work hard to eliminate this possibility from our practice and wherever we discover such conduct in violation of law we will not hesitate to alert law enforcement.
By signing this electronic signature, I attest that I have PPO insurance, and that I have read and understood the above drug abuse diversion policy and will abide by its rules. I also understand that if I have seen another pain doctor before, I must attach my previous doctors visit notes to this form or have them fax my visit notes to Pain Medicine Consultants at (925) 287-0913.
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