MICHAEL J. DORSI, MD
Ventura County Neurosurgical Associates Medical Group
168 N. Brent St., Suite 408
Ventura, CA 93003
Office: (805) 643-2179
Fax: (805) 643-0672
NEW PATIENT REFERRAL
Referring Provider Information:
Name:
Phone:
Fax:
Patient Information:
Name:
Date of Birth:
Address:
Phone:
Insurance:
Reason for consultation (circle):
Spine
Brain
Peripheral Nerve
Herniated disc
Tumor
Carpal tunnel syndrome
Neck/back pain
Trigeminal neuralgia
Cubital tunnel syndrome
Radiculopathy
Hydrocephalus
Other nerve entrapment
Myelopathy
Chiari malformation
Nerve/brachial plexus injury
Stenosis
Hematoma
Nerve tumor
Spinal tumor
Thoracic outlet syndrome
Other:
_______
***Please attached all relevant studies and reports***
FAX : (805)-643-0672