Patient Forms & Documents
Download, print, and complete our forms before your visit — every form is available in English and Spanish.
For referring providers
Referring a patient to United Neuroscience Institute? Complete the referral form below and fax it, together with the applicable medical records, to (661) 324-0600. Please include a copy of the patient's photo ID, the front and back of all insurance cards, and a current demographic sheet. Questions about a referral can go to our office at (661) 324-0500.
Neurology Referral Form
For referring providers — patient details, reason for and urgency of the referral, preferred specialty, and the records to send with it. Fax the completed form and records to (661) 324-0600.
Patient forms
These are the standard forms we ask patients to review, complete, and sign. Click a form to preview it in your browser first — from the preview you can print it or save it to your device. Bringing completed forms to your appointment usually makes check-in faster, and printed copies of every form are also available at the front desk.
Bring a photo ID and your insurance card to your first visit along with your completed forms. If you are not sure which forms apply to your visit, or you have questions about anything a form says, call our office at (661) 324-0500 and our staff will walk you through it.
New Patient Intake Form
Demographics, insurance, pharmacy, medications, allergies, and your medical, family, and neurology history — complete this before your first visit.
Telehealth Consent
Consent to receive care through video or phone visits, and what telehealth can and cannot do.
Notice of Privacy Practices
How your health information may be used and disclosed, and your privacy rights under HIPAA.
Financial Agreement & Assignment of Benefits
Your payment responsibilities and authorization for us to bill your insurance directly.
Authorization to Disclose Health Information
Lets us share your medical records with the people and providers you choose.
Electronic Appointment Reminders Agreement
Consent to receive appointment reminders by text message or email.
We're here for you.
Call our Bakersfield clinic or send us a message — we are here to assist you.