Los Altos Neurology | SimplePractice

Who would be receiving care?

Someone else

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

What sex is on your insurance policy?

For insurance verification

State

Select the state you live in

Zip Code

Administrative

Relationship to Patient (e.g., self, spouse, daughter, niece)

Determination of Care

I understand that completing this form does not establish a patient-physician relationship. Due to high demand, we are only able to contact prospective patients whose needs align with the scope of our practice. While we review all submissions, we may not be able to respond to every inquiry.

Email Consent

I consent to receiving email communications from Los Altos Neurology regarding my inquiry, including information about out-of-network services, fees, and practice policies.

Billing & Payment

Billing Disclosure

I understand that Los Altos Neurology is an out-of-network practice and that services are provided on a self-pay basis.

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.