• Home
  • First Visit
  • FAQ
  • About Me
  • Seizures
  • Concussions
  • More
    • Home
    • First Visit
    • FAQ
    • About Me
    • Seizures
    • Concussions
  • Home
  • First Visit
  • FAQ
  • About Me
  • Seizures
  • Concussions

Dr. Melissa Przeklasa Auth M.D.

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 

To send outside records to our office, please complete a Release of Records form.

Record Release Authorization

Privacy Notice

Record Release Authorization

New Patient File Downloads

New Patient Packet (pdf)Download
New Patient Development/Educational Packet (pdf)Download
New Patient Headache Packet (pdf)Download
New Patient Concussion Packet (pdf)Download
Notice of Privacy Practices 2025 (pdf)Download
Record Release Authorization 2025 (pdf)Download
Parent Vanderbilt Form (pdf)Download
Teacher Vanderbilt Form (pdf)Download

Orange County Child Neurology

30131 Town Center Drive Suite # 237, Laguna Niguel, California 92677, United States

Phone: 949-495-6100 Fax: 949-354-0612

Email us!

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

Copyright © 2025 Orange County Child Neurology - All Rights Reserved.


Powered by