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Please print this form, fill it out and fax it to Dr. Read's office at:

(310) 521-8112

or mail it to:

1621 West 25th St., #225
San Pedro, CA 90732


[ ] female

[ ] widowed

Part 1: Patient Information

Name_____________________________

Address__________________________

City___________State____Zip______

Birthdate____/____/____

Telephone(____)________

SSN______-______-______

[ ] male

[ ] divorced

[ ] single

[ ] married


Part 2: Patient Accompanied By: (primary contact/responsible party)

Name______________________________

Relation__________________________

Address___________________________

City___________State____Zip_______

Telephone(H)(____)________________

Telephone(W)(____)________________

Name______________________________

Relation__________________________

Address___________________________

City___________State____Zip_______

Telephone(H)(____)________________

Telephone(W)(____)________________


Part 3: Primary Physician(s)

Dr._______________________________

Address___________________________

City___________State____Zip_______

Telephone(____)___________________

Dr._______________________________

Address___________________________

City___________State____Zip_______

Telephone(____)___________________


Part 4: You were referred to us by:

Name______________________________

Address___________________________

City___________State____Zip_______

Telephone(____)___________________

Part 5: Acknowledgment:

I accept all financial responsibility for services rendered.

A copy of this is as valid as the original.

OR





Patient Signature

Patient Representative

Relationship

Date

Please print this form, fill it out and fax it to Dr. Read's office at:

(310) 521-8112

or mail it to:

1536 W. 25th St., PMB 340
San Pedro, CA 90732

Also, prior to the appointment, Dr. Read would like, if available:

1) Recent blood work (last 6 months): CBC-diff; chem panel (electrolytes, BUN, Creatinine, liver function); thyroid function (TSH); B12 level

2) Discharge summaries from recent (this past year) hospitalizations

3) Current medication list (dosage and directions)

4) Anecdotal information from caregivers, caseworkers and /or family members outlining main issues of concern via fax or email

5) Brain scans - CT, MRI, SPECT, PET, EEG (within the last 2 years)

6) Most recent EKG (electrocardiogram)

7) All Consultation Reports of the past 12 months

We understand that all of this information may not pertain to you, but at a minimum, Dr. Read almost always likes copies of recent blood work and a current list of medications. In addition, information about previously prescribed medications including doses, durations, and response, if available, can be very helpful.