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Orange County Child Neurology

Dr. Melissa Przeklasa Auth M.D.

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FORMS REQUESTED PRIOR TO YOUR INITIAL VISIT

NO LATER than 10 days after you SCHEDULE your first visit, please send in the following via fax (949) 354-0612 or email to occhildneuro@gmail.com:

     Fill out all forms in BLACK ink ONLY.

         Insurance Card (Front/Back)

          Parent Questionnaire

          Demographics Information

          Protected Health Information Consent

          Financial Agreement

          Medication Policy


Additional Forms for Migraine/Headache Evaluation:

     Headache Diary


Additional Forms for Concussion:

     ImPACT Testing Form


Additional Forms for ADHD/ADD Evaluation:

    Parent Vanderbilt Form

    Teacher Vanderbilt Form


If you have outside records you wish to have sent to our office, please fill out the Release of Records form.

     Record Release Authorization


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