PPO Patient Appointment Request Form

Patient Information

Patient Name

Best Contact Phone Number

Patient Email

Address

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

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

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?

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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