New Patient

Patient Intake Forms

Please complete these forms before your visit. You can fill them out here, print them, or both.

VEENA SENGUPTA, M.D.Diplomate, American Board of Neurology
LEON BARKODAR, M.D.Diplomate, American Board of Neurology
ADEL OLSHANSKY, M.DDiplomate, American Board of Neurology & Clinical Neurophysiology
DESIREE LEVYIM, M.D.Adult and Pediatric Neurology
7301 MEDICAL CENTER DR STE 410, WEST HILLS, CA 91307  |  PHONE: (818)593-2191  |  FAX: (818)593-2194
Your information stays on your device until you choose to send it.
Section 1

New Patient Intake

Name
Date of Birth
Age
SSN
Home Address
City
State
Zip Code
Home Phone
Cell Phone
Email
Emergency Contact
Emergency Contact Phone Number
Primary Care Physician
Phone
Fax
Address
City
State
Zip Code
Referring Physician (if different from PCP)
Specialty
Phone
Fax
Address
City
State
Zip Code
Pharmacy Name & Cross Streets
Phone
Release of Information (HIPAA Privacy Act) (Valid until otherwise told different)
Who may we share your medical information with?
Where may we leave medical information?

Communication methods such as Facetime and email are non HIPAA compliant and are available with your consent.

Initials

You understand that your information may be shared with your health providers.

Initials
Section 2

Reason for Visit & Histories

Reason for visit – Chief Complaint (History of Present Illness)
Is this visit related to worker's compensation?
Is this visit related to any legal actions?
If this problem is the result of an accident, when did the accident occur?
Surgical History (Please list all operations you have had)
Operation
Date
Operation
Date
Operation
Date
Operation
Date
Medical History (Please list all active medical conditions)
Condition
Duration
Condition
Duration
Condition
Duration
Condition
Duration
Current Medications, prescribed or over the counter
Medication Name
Dose
Frequency
Medication Name
Dose
Frequency
Medication Name
Dose
Frequency
Medication Name
Dose
Frequency
Medication Name
Dose
Frequency
Medication Name
Dose
Frequency
List all allergies and sensitivities (e.g. medications, foods, latex, iodine, etc.)
Are you taking any "blood thinning" medications?
Social History
Occupation
Marital Status
Number of Children
Do you smoke cigarettes?
If so, how many packs a day?
Do you drink alcohol?
If so, how much daily?
At what age did you start?
If applicable, at what age did you stop?
Section 3

Lifestyle, Family History & Review of Symptoms

Do you use recreational drugs?
What type?
Do you exercise regularly?
How frequently?
Height
Weight
Are you or could you be pregnant?
Family History (Do you have a family member affected by any of the following?)
ConditionType & Relative
Brain tumor
Seizures or Epilepsy
Dementia
Parkinson's
Multiple Sclerosis
Thyroid disease
Muscle disease
Neuropathy
Hypertension
Diabetes
Migraines
Other conditions?
Review of Symptoms (Do you currently have or had a problem with?) Check all that apply.
Constitutional
Fever
Weight loss >5 lbs
History of Falls
Genitourinary
Urinary tract infections
Painful urination
Blood in your urine
Difficult starting/stopping stream
Incontinence
Kidney stones
Endocrine
Diabetes
Thyroid disease
Excessive thirst/urination
Eyes
Vision changes
Ear, Nose, Throat & Mouth
Wear hearing aid(s)
Hearing loss
Ear pain/infections
Ringing in ears
Nasal congestion/drainage
Section 4

Review of Symptoms (continued)

Do you currently have or had a problem with? Check all that apply.

Musculoskeletal
Broken bones
Arm or leg weakness
Arm or leg pain
Joint pain or swelling
Arthritis
Cardiovascular
Chest pain or angina
Irregular pulse
Heart Murmur
Swelling in hands or feet
Respiratory
Asthma
Shortness of breath
Breathing difficulty
Gastrointestinal
Nausea
Vomiting
Change in bowel habits
Ulcers or gastritis
Hematologic/Lymphatic
Anemia
HIV
Allergic/Immunologic
Food, Nasal allergies
Autoimmune disease
Smell / Sinus / Balance
Inability to smell
Sinus problems
Balance (vertigo, spinning, etc.)
Integumentary
Skin disease
Breast pain, tenderness
Nipple discharge
Unusual moles
Neurological
Fainting spells or "black outs"
Headaches
Seizures
Memory problems
Disorientation
Speech difficulty
Inability to concentrate
Double or blurred vision
Weakness in arms and/or legs
Loss of sensation
Difficulty with balance
Psychiatrics
Anxiety
Depression
Section 5

Authorization to Release Medical Records

Patient Name
Date of Birth
Phone Number
I authorize doctor or group name:
Phone Number
Fax Number
To release the following health/medical records relating to my identity, diagnosis, and prognosis and/or treatment:
to
Records to be sent to:
Facility or entity name
Phone
Release via
Reason for record release:
Patient Signature
Date

This release of records shall remain in force until revoked in writing.

Section 6

Cancellations and No Show Policies

  1. Scheduled Appointments: We understand that delays can happen; however, we must try to keep the other patients and doctors on time. If a patient is 15 minutes past their scheduled time, we will have to reschedule the appointment.
  2. Cancellation/No Show Policy for Doctor Appointments: We understand that there are times when you must miss an appointment due to emergencies. However, when you do not call to cancel an appointment, you may be preventing another patient from getting much needed treatment. If an appointment is not cancelled at least 48 hours in advance, you will be charged a fifty dollar ($50.00) fee.
  3. Cancellation/No show Policy for EEG and Nerve Study Appointments: Due to the large block of time needed for these appointments, last minute cancellations or no shows can cause problems and added expenses for the office. All EEG and Nerve Study appointment cancellations after 48 hours will incur a one hundred ($100.00) fee; a no show will also incur this fee.
  4. This charge cannot be billed to the insurance company. No showing or late cancelling (3) appointments can result in the patient being discharged from the practice, at the physician's discretion. Fees will only be waived in case of emergency — for example, death in the family, hospital admission, or illness. We reserve the right to refuse service to anyone with an unpaid balance.

I have read and understood the cancellation and no show policy.

Patient name
Patient Signature/or guardian
Date
Section 7

Notices

Medical Debt Notice (California SB-1061)

(c) (1) On or after July 1, 2025, it is unlawful to enter into a contract creating a medical debt that does not include the following term: "A holder of this medical debt contract is prohibited by Section 1785.27 of the Civil Code from furnishing any information related to this debt to a consumer credit reporting agency. In addition to any other penalties allowed by law, if a person knowingly violates that section by furnishing information regarding this debt to a consumer credit reporting agency, the debt shall be void and unenforceable." (2) A contract entered into on or after July 1, 2025, that does not include the term described in paragraph (1) is void and unenforceable. (d) A violation of this section by a person holding a license or permit issued by the state shall be deemed to be a violation of the law governing that license or permit.

Patient or guardian signature
Date

California Law Requires Notice to Patients About Open Payments Database

The Open Payments Database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals which can be found at https://openpaymentsdata.cms.gov.

Copy of written notice available upon request.

Patient or guardian signature
Date
Section 8

Patient Financial Agreement & Acknowledgment of Office Policies

Our practice believes that part of good health care practice is to establish and communicate an office and financial policy to our patients. We are dedicated to providing the best possible care for you, and we want you to completely understand our policies.

  1. Payment: is expected at the time of your visit. We accept cash, checks, or credit cards. Payment will include any unmet deductible, co-insurance, copayment amount, or non-covered charges from your insurance company. If you do not carry insurance, or if your coverage is currently under a pre-existing condition clause, payment in full is expected at the time of your visit.
  2. Insurance: We are participating providers with several insurance plans. We will file all of the insurance claims for these plans. Please remember that insurance is a contract between the patient and the insurance company and ultimately the patient is responsible for payment in full. If your insurance company does not pay the practice within a reasonable period of time, you will be billed. If we later receive payment from your insurer, we will refund any overpayment to you. In order to bill your insurance and to meet filing guidelines we do ask for a copy of your policy card and an ID or license is now required due to many cases of identity theft. If our providers are not listed in your plan's network, you may be responsible for partial or full payment. If you are insured by a plan with which we have no prior arrangement, we will prepare and send the claim for you on an unassigned basis. This means the insurer may send the payment directly to you and therefore, our charges for you are due at the time of service. Due to the many insurance products out there, our staff cannot guarantee your eligibility and coverage. Especially, patients with HMO plans need to be eligible at the time of service with their health plan with a valid authorization. It is your responsibility to check with your insurer's member benefits department about services and providers before your appointment.
  3. Returned checks: Will incur a $25.00 service charge. You will be asked to bring cash, certified funds or a money order to cover the amount of the check plus the $25.00.
  4. Balance: Bill Text - SB-1061 Consumer debt: medical debt. Section 1785.27 is added to the Civil Code, to read: (a) A person shall not furnish information regarding a medical debt to a consumer credit reporting agency. (b) A medical debt is void and unenforceable if a person knowingly violates this section by furnishing information regarding the medical debt to a consumer credit reporting agency.

I hereby authorize to furnish to the provided insurance companies all information which the insurance companies may request. I hereby assign all basic and major medical benefits to which I am entitled for medical expenses related to the services rendered, but not to exceed indebtedness that is due. I understand that money received from the insurance companies will be refunded when my bill is paid in full. I understand that I am financially responsible to the said doctor for charges not covered by the insurance companies.

(Attention Medicare Patients: Certain tests may not be covered by Medicare. By signing below, you are agreeing that you are choosing to have any test(s) done whether today or in the future. This is collected on "Advanced Beneficiary Notice." You may, however, decline to do any test.)

The information on this form is accurate to the best of my knowledge:

Patient name or guardian
Patient Signature
Date

How to send this form

1Fill out the form above — everything stays on your device.
2Click Print / Save as PDF to create a copy of your completed forms.
3Email the PDF to office@neurologylosangeles.com — or bring the printed forms to your visit. Please also attach a photo of your ID and insurance card.
Email the office