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?OutIn Patient 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?YesNo Can Eat Well?YesNo Explain: Can Walk Well?YesNo Explain: Treatment Summery: Patient has filled out HIPPAYesNo If No Hippa, Explain Why?
