Patient Forms

Please fill out the appropriate forms prior to your appointment. This will help you get in and out of the office faster. If you have any questions about which forms to fill out or how to fill them out you can always give us a call at 310-836-2225.

 

NEW WAY TO COMPLETE OUR FORMS:  DIGITALLY!

Click one of the links below and you can do it on your phone, computer, ipad and we receive your answers in our Updox portal. if you are unsure which to complete, ask Cristina on phone or email.  If you have chronic pain, neuroplastic symptoms or think you have TMS and are a new patient, the first link.   If you are a new patient coming in for a Physical or Preventive Care, 2nd link.  If you are a new patient for a sports injury, general medical issue or simple med refills, the 3rd link.  An existing patient can complete the forms for the annual Physical with the 4th link.  

 

 NEW PT (TMS)


NEW PT (PE)


NEW PT (GENERAL)


PHYSICAL (PHQ + SHQ):

 

FOLLOWUP VISIT FORM:   

 

MEDICARE CONTRACT:  (you have Medicare and you acknowledge that Dr. Schechter is not a provider)

 

Our Usual Method– Required New Patient Forms (PDF’s)

Patient Info/Demo

HIPAA Consent--To Read and Sign

Review of Systems

Notice of Privacy--To Read

Patients Who Have TMS (chronic pain) Should Also Complete (PDF’s)

 

TMS Questionnaire

Pain Diagram

Visual Analogue Scale (VAS)

Other Forms (optional or specific reasons) (PDF’s)

Advanced Health Directive

Medicare Private Contract