Patient Forms

The following forms are available for download:

Please print and fill out the form and bring it to our office.

Coming soon: Fill out your New Patient Packet online!

Please be sure to bring the following to your appointment:

  • Your most current diagnostic films and reports (e.g. MRI, CT, plain x-rays; SSEP or EMG reports; Physical Therapy reports; Pain Medicine reports, etc.) pertaining to your current medical condition. (PLEASE NOTE: If your Films were done within the Good Samaritan system at Santa Monica or Westwood, our office will make sure that they are here for your visit and you do not need to pick up these films. However, if you had films done outside of UCLA, you do need to bring these with you).

  • Prior medical records and consultations from your referring physician and any other specialist you’ve seen for your current condition. To help expedite your visit, please hand carry your reports to this office. Do not send them prior to your appointment.

  • Your medical insurance card (s)

  • If you have HMO Insurance: Please be sure to bring your “Letter of Authorization: from your HMO. If you do not bring your authorization letter and we do not have written authorization on file, you will be financially responsible and will be asked to pay the consultation fee on the day of your appointment.

  • If you have HMO or PPO Insurance: Please be sure to bring your co-payment with you. We accept cash, check, or Visa/ Mastercard / American Express.

If you have any questions, please feel free to contact The Spine Clinic of Los Angeles at (213) 481-8500. We look forward to seeing you.

PLEASE NOTIFY US OF ANY CANCELLATIONS AT LEAST 24 HOURS PRIOR TO YOUR APPOINTMENT

 

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Copyright ©2013 Larry T. Khoo, MD · The Spine Clinic of Los Angeles
1245 Wilshire Blvd., Suite 770 · Los Angeles, CA 90017
For scheduling and general questions call: 213-481-8500