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Patient Information

Please ensure you submit your Consent Forms prior to scheduling an appointment. For any questions or concerns regarding these forms, please contact us at (424) 255-5917 or email info@cescamedicalgroup.com. We strive to respond promptly to all inquiries Monday To Saturday.

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    Patient Information

    Preferred Pharmacy(Optional)

    INSURANCE INFORMATION

    PRIMARY INSURANCE

    INSURANCE INFORMATION

    SECONDARY INSURANCE

    AS PATIENT, OR AS LEGAL GUARDIAN OF MINOR PATIENT, I AGREE TO PAY FOR ALL SERVICES RENDERED. THIS OFFICE MAY BILL MY INSURANCE CARRIER AS NEEDED. I AM FINANCIALLY RESPONSIBLE FOR ALL NON-COVERED SERVICES. I AUTHORIZE THIS OFFICE TO RELEASE MY INFORMATION TO PROCESS ANY REQUESTS.

    Generalized Anxiety Disorder (Anxiety Assessment)

    Over the last 2 weeks, how often have you been bothered by the following problems?
    Not At All
    Several Days
    More Than Half Days
    Nearly Half Days
    0
    1
    2
    3
    0
    1
    2
    3
    0
    1
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    3
    0
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    3
    0
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    3
    0
    1
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    3
    0
    1
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    3

    Patient Health Questionnaire (Depression Assessment)

    Over the last 2 weeks, how often have you been bothered by any of the following problems?
    Not At All
    Several Days
    More Than Half The Days
    Nearly Half A Days
    0
    1
    2
    3
    0
    1
    2
    3
    0
    1
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    3
    0
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    PTSD Checklist 5 (PCL-5)

    Stressful life experiences. How much you have been bothered by that problem IN THE LAST MONTH.
    Not At All
    Several Days
    More Than Half Days
    Nearly Half A Days
    0
    1
    2
    3
    0
    1
    2
    3
    0
    1
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    3
    0
    1
    2
    3
    0
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    Credit Card Information

    Terms & Conditions of Cesca Medical Group

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    Locations
    • CESCA MEDICAL GROUP INC
      California: 15424 Hawthorne Blvd STE 302, Lawndale, CA 90260-2175
    • Health Core Medical Group LLC
      Nevada: 6845 W. Charleston Blvd. Suite A, Las Vegas NV 89117
    Contact
    Open time

    Monday – Saturday……………….11am-7pm
    Tuesday -Saturday………………..11am-8pm
    VPM services and administrative services end Friday, however the provider is available to see patients on Saturdays

    Copyright © 2023 CESCA MEDICAL GROUP INC & Health Core Medical Group LLC