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GLOBAL CONSULTATION

If you would like more information on Minimally Invasive Spinal Surgery treatment, Dr. John Chiu can provide you with a global consultation and recommend spinal treatment options. The cost for the consultation is $350.00. Please complete the form below and forward us your MRI, CT, and X-rays on CD or films and include relevant medical reports to the following address:

California Spine Institute Medical Center
Attn: Global Consultation
1001 Newbury Road
Thousand Oaks CA 91320
Telephone:
800.354.8554
Facsimile: 805.375.7975

If you have any questions contact us at 800-354-8554. Thank you for your request and we are looking forward to hearing from you.

  PATIENT INFORMATION
Patient Name:
D.O.B.:
City:
Phone:
Alternate Phone:
Fax:
Email:
REFERRAL DOCTOR
Doctor's Name:
Doctor's Phone:
HOW CAN WE HELP YOU?
Symptoms and
Medical History:
Questions for
Doctor Chiu:

    Per HIPAA requirements you must read and sign the Joint Notice of Privacy Practices prior to any response to this request. California Spine Institute Medical Group, Inc.

    I acknowledge that I have received a copy of California Spine Institute’s Joint Notice of Privacy Practices

    Please click here to view and print the HIPPA Complance Information.

ACKNOWLEDGEMENT OF RECEIPT
Acknowledged:
Date:
Representative
(if applicable):
INSURANCE INFORMATION
Account Number:
PAYMENT INFORMATION

No spaces, please.
Expiration Date: