Spectrum Care & Wellness
255 E. Orange Grove Ave Suite A, Burbank, CA 91502 | Phone: 818.848.3333 | Fax: 818.848.3337
Catherine Chern, MD
|
Christine Szeto, MD
PATIENT INFORMATION:
Patient Name: DOB: Gender:
Male
Female
SSN:
-
- Marital Status: Single
Married Separated
Widowed Widower Domestic Partner
Primary language:
Address:
City: State:
Zip Code:
Preferred phone#: Mobile Home Alternate phone #: Mobile Home
Email Address: Driver’s License #:
Employer: Occupation: Phone #:
Address:
City: State:
Zip Code:
GUARANTOR INFORMATION: (Main Subscriber of Insurance)
Guarantor Name: Relation to patient:
Address:
City: State:
Zip Code:
Employer:
SSN:
- - Phone #:
DOB:
EMERGENCY CONTACT INFORMATION:
Contact Name: Relationship to patient:
Preferred phone#: Mobile Home Alternate phone #: Mobile Home
INSURANCE INFORMATION:
Primary Insurance: Certificate #: Group #:
Subscriber Name: Relation to patient:
Subscriber SSN: - -
DOB:
Employer:
Secondary Insurance: Certificate #: Group #:
Subscriber Name: Relation to patient:
Subscriber SSN: - -
DOB:
Employer:
Additional Notes:
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