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FORMS REQUESTED PRIOR TO YOUR INITIAL VISIT

We request paperwork prior to SCHEDULING 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 Evaluation:

     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


Privacy Notice


Orange County Child Neurology Dr. Melissa Przeklasa Auth Pediatric Neurologist Laguna Niguel

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Orange County Child Neurology

Dr. Melissa Przeklasa Auth M.D.

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