Appointment Instructions Sheet
Dear parent, please be sure you have received your authorization before scheduling your child’s follow-up appointment.
Follow-up with Primary Care Physician: This is the doctor that you visit for your child’s routine care, school physicals and immunizations.
Name: ___________________ Phone Number: ___________
Appointment Date: _________ Appointment Time: _________
| Other Services | Physicians |
Follow-up with Neurologist: This appointment is to be made after you receive a referral from your child's Primary Care Physician. This is the doctor who may order tests or medications for conditions of the brain(such as seizures), spinal cord, and nerves.
Name:__________________ Phone Number: 714-532-7601
Appointment Date:________ Appointment Time:_________
Authorization Number:_________ Expiration Date:_______
Insurance:_______________ Consult Info:_____________
Physician:_______________ Phone Number:____________
* To contact the other service departments, please contact
