Mandatory Information:
Lead Source
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Internet
Facebook
TV Commercial
Billboard
Doctor Referral
Attorney Referral
Family/Friend
Other
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Name of Intake Staff
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Daly Rosario
Ingrid Fabregas
Paula Lapas
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Patient Full Name
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Email
Phone
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Address
Date of birth
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Insurance Type: (Choose One)
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Major Med
Medicare
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W.C.
PIP/No-Fault
LOP
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Insurance Policy Number
Intake Form
What is the problem?
How were you injured? (at work, car accident, etc.)
If it was a car accident, or work-related injury - ask if they have an attorney.
Date of Injury
Have you had any treatment yet?
Chiropractic
Pain Management
Physical Therapy
Orthopedic
Ortho-Spine
Neuro-Spine
Neurologist
Other?
If yes, who was the doctor, and what was done?
Have you had any imaging done?
X-ray?
MRI?
CT?
If yes, where was your imaging done?
Referred To:
Choose One
Dr. Fabien Bitan
Dr. Anders Cohen
Dr. Daniel Dorri
Dr. Mostafa El Khashab
Dr. Jason Gallina
Dr. Luis Grau
Dr. Michael Gerling
Dr. Praveen Kadimcherla
Dr. Teja Karukonda
Dr. Sunil Kukreja
Dr. Joshua Landa
Dr. Sebastian Lattuga
Dr. Johnathan Lewin
Dr. Adam Lipson
Dr. Gbolahan Okubadejo
Dr. Sujal Patel
Dr. Rajnik Raab
Dr. Paul Ratzker
Dr. Joshua Rovner
Dr. Edward Sheid Jr
Dr. Harshpal Singh
Dr. Alok Sharan
Dr. Ashley Simela
Dr. Branko Skovrlj
Dr. Tamir Tawfik
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Patient appointment confirmed
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