0 demo Note: shortly after you fill out this application you will be receiving a phone call from one of our friendly coordinators. Please be on the look out for a phone number with a 619 area code. Patient Intake:Arrival Date:Departure Date:Out or In Patient?OutInPatient Name: Patient Cell Phone: Preferred Nickname: Patient Date of Birth: Street 1: Street 2: City: State: Zip Code: Country: Location: Time: Flight Info:Companion Name:Companion Cell Phone:Needs Wheel Chair?YesNoCan Eat Well?YesNoExplain: Can Walk Well?YesNoExplain:Treatment Summery:Patient has filled out HIPPAYesNoIf No Hippa, Explain Why?Δ
