Neuron Medical Corporation is the neurology practice of Liliana Cohen, M.D., Paul Dudley, M.D. and naturopathic medical doctor Kristin Stiles Green, N.M.D. of Thousand Oaks, California. 

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Appointment

What to Bring to the Appointment

  • Your insurance card
  • Physician referral forms if required by insurance
  • A list of current prescriptions and/or over-the-counter medications you are taking, including dose and frequency
  • Pertinent information about your medical and surgical history
  • Any recent x-rays or appropriate records you may have

Insurance and Payment Information

Neuron Medical Corporation is a provider for Medicare and most major insurance plans. We provide insurance billing. Anything not covered by insurance will be your responsibility.

We request payment at the time of your appointment for services that are not covered by insurance. Your insurance company may also require you to pay a co-payment at the time of your appointment. When necessary, our staff will work closely with patients who require a payment plan.

If you have any questions regarding which insurance plans we accept or any patient billing concerns, please call us at the phone number below. Questions regarding your coverage and benefits should be directed to your employer or insurance company.

Hospital Affiliations

Dr. Cohen and Dr. Dudley are affiliated with the following medical facility:

Patient Forms

Click on the following links to download and print our patient forms and send to email neuronoffice@gmail.com, or fill online .

New Patient Forms – Neurology:

    New Patient Information sheet


    The fields marked with * are mandatory


    Date of birth*

    RESPONSIBLE PARTY, SIGNIFICANT “OTHER” OR SPOUSE INFORMATION

    INSURANCE INFORMATION

    PHARMACY INFORMATION

    I hereby assign, transfer and set over to Neuron Medical Corp. all of my rights, title and interest to my medical reimbursement benefits under my insurance policy. I authorize the release of any medical information needed to determine these benefits. This authorization shall remain valid until written notice is given by me revoking said authorization. I understand that I am financially responsible for all charges whether or not they are covered by insurance. A $50.00 cancellation fee will be charged to any and all patients who do not cancel their appointment within 24 hours prior to their scheduled appointments.

    Date of completion*

    The fields marked with * are mandatory

      Neurology Patient History Form

      PATIENT DATA


      (If you are here for a return visit, you may complete only side one if other information is unchanged.)

      1.Please describe the problem that prompted your appointment and your goals for this visit.

      2. Please supply the following information:

      I am:

        right-handed

       

       

      3.Please neatly write your current medications (include dose size and number of times a day taken).

      Daily Medications: As needed, Herbal or OTC meds Allergies:

      4.Which symptoms have you experienced in the last month? Please check all that apply

      REVIEW OF SYSTEMS
        Abdominal pain   Double vision   Ringing in ears
       Back pain  Fatigue  Shortness of breath
        Blood in urine   Faintness   Sinus congestion
        Bruise easily   Headache   Sleep problems
        Burning with urination   Heart palpitations   Snoring
        Chest Pain   Heartburn   Teeth or gum problems
        Chest Pressure   Joint pain   Tremors
        Chills   Memory loss   Urinary frequency
        Constipation   Muscle pain   Incontinence
        Cough,chronic   Muscle tenderness  Vision disturbance or change
        Depression  Nausea  Weakness
        Diarrhea   Vomiting   Weight gain
        Difficulty with swallowing   Neck pain   Weight loss, trying
        Dizziness   Panic attack   Not trying
          Rash  

      5.If you have headaches, back pain or other pain, please complete the following section

        Check here if you do not have a problem with pain.

      PAIN ASSESSMENT
      Location of pain Radiation (where does pain move):
      Duration (how long does pain last):
      Severity − How bad is the pain on a 1-10 scale, with 10 the worst pain you can imagine: / 10  
      Timing – pain occurs most:  morning;   afternoon; evening; night;   any time;  wakes me from sleep
      Quality:   dull;   stabbing;   sharp;   burning;   throbbing;
       other (describe):
      Recent change – pain is: worse;   better;     more frequent;  less frequent;    no recent change;
        I am taking pain meds;   I am using a pain control strategy.
      Current therapy is:   working well;    not working.
      6.MEDICAL HISTORY (Check and write the year this was diagnosed)  
      Alcoholism Headaches Seizures, epilepsy
      Angina Hypertension(High blood pressure) Seizures, nonepileptic
      Anxiety Hyperthyroidism Shingles
      Arthritis Hypothyroidism Sinusitis
      Asthma Infertility Skin cancer
      Bowel problems Kidney problems Systemic Lupus rythematosus
      Cancer: Type Kidney stones Sleep apnea
      Cardiac Arrhythmias (A-fib) Lipid disorders, high cholesterol Stroke TIA (mini-stroke)
      Cardiac disease(heart disease) Liver conditions Syncope (fainting)
      COPD, emphysema Meningitis Tremor
      Dementia Multiple sclerosis Ulcer
      Depression Myopathy (muscle disease) Uterine: Endometriosis
      Diabetes mellitus Neuropathy Fibroids
      Fibromyalgia Gastritis or GERD Parkinson’s Disease
          Trauma/accident
      Other:    
      Other:    
      7.PRIOR SURGICAL PROCEDURES (Check and write the year of the surgery)
      Back surgery Laparoscopy
      Brain surgery Mastectomy
      CABG, Coronary artery bypass (Heart bypass) Neck surgery
      Carotid endarterectomy: Right; Left; Sinus surgery
      Cataract surgery Spine surgery
      Cholecystectomy Tonsillectomy and adenoids
      C-section Tubal ligation
      Hysterectomy / Ovaries removed also TURP, prostate surgery
      Hip surgery / Knee surgery    
      Other:

      8.Which of these tests have you had? Please check appropriate boxes.

      MEDICAL EVALUATIONS (check the place and date of the test)
      MRI EEG Carotid Doppler
      CT EMG/NCS Echocardiographph

      9.Please check appropriate boxes

      SOCIAL HISTORY

      I am DISABLED; RETIRED

      Marital Status: SINGLE; MARRIED; DIVORCED; SEPARATED; WIDOWED;

      Habits:

      caffeine:

      smoking

      alcohol: drug use;  

      Education: some High School; HS Diploma; College

      Graduate/Professional School

      ABUSE SCREEN: Have you suffered emotional, physical or sexual abuse?

      10.Which of these diseases run in your family? Please mark with "x" all that apply.

      FAMILY HISTORY (list the relative involved next to the diagnosis)
      Alcoholism Domestic violence Multiple sclerosis
      Alzheimer’s Drug abuse Neuropathy
      Brain Aneurysms Elevated cholesterol Parkinson’s
      Cancer Heart disease
      Schizophrenia
      Depression High blood pressure Seizures
      Diabetes mellitus Migraine Stroke

      Father:

      Mother:

      Siblings:





      PHYSICIAN-PATIENT ARBITRATION AGREEMENT

      Article 1: Agreement to Arbitrate: It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, will be determined by submission to arbitration as provided by California law, and not by a lawsuit or resort to court process except as California law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration.

      Article 2: All Claims Must Be Arbitrated: It is the intention of the parties that this agreement shall cover all claims or controversies whether in tort, contract or otherwise, and shall bind all parties whose claims may arise out of or in any way relate to treatment or services provided or not provided by the below identified physician, medical group or association, their partners, associates, associations, corporations, partnerships, employees, agents, clinics, and/or providers (hereinafter collectively referred to as “Physician”) to a patient, including any spouse or heirs of the patient and any children, whether born or unborn, at the time of the occurrence giving rise to any claim. In the case of any pregnant mother, the term “patient” herein shall mean both the mother and the mother’s expected child or children.
      Filing by Physician of any action in any court by the physician to collect any fee from the patient shall not waive the right to compel arbitration of any malpractice claim. However, following the assertion of any claim against Physician, any fee dispute, whether or not the subject of any existing court action, shall also be resolved by arbitration.

      Article 3: Procedures and Applicable Law: A demand for arbitration must be communicated in writing by U.S. mail, postage prepaid, to all parties, describing the claim against Physician, the amount of damages sought, and the names, addresses and telephone numbers of the patient, and (if applicable) his/her attorney. The parties shall thereafter select a neutral arbitrator who was previously a California superior court judge, to preside over the matter. Both parties shall have the absolute right to arbitrate separately the issues of liability and damages upon written request to the arbitrator. Patient shall pursue his/her claims with reasonable diligence, and the arbitration shall be governed pursuant to Code of Civil Procedure §§ 1280-1295 and the Federal Arbitration Act (9 U.S.C. §§ 1-4). The parties shall bear their own costs, fees and expenses, along with a pro rata share of the neutral arbitrator’s fees and expenses.


      Article 4: Retroactive Effect: The patient intends this agreement to cover all services rendered by Physician not only after the date it is signed (including, but not limited to, emergency treatment), but also before it was signed as well.

      Article 5: Revocation: This agreement may be revoked by written notice delivered to Physician within 30 days of signature and if not revoked will govern all medical services received by the patient.

      Article 6: Severability Provision: In the event any provision(s) of this Agreement is declared void and/or unenforceable, such provision(s) shall be deemed severed therefrom and the remainder of the Agreement enforced in accordance with California law.

      I understand that I have the right to receive a copy of this agreement. By my signature below, I acknowledge that I have received a copy.

      NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HA VE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE I OF THIS CONTRACT.

       

      A signed copy of this document should be given to the patient. The original copy will be archived in the patient’s medical file.

      New  Patient Forms – Naturopathic Medicine / Dr. Green:

        New Patient Information sheet


        The fields marked with * are mandatory


        Date of birth*

        RESPONSIBLE PARTY, SIGNIFICANT “OTHER” OR SPOUSE INFORMATION

        INSURANCE INFORMATION

        PHARMACY INFORMATION

        I hereby assign, transfer and set over to Neuron Medical Corp. all of my rights, title and interest to my medical reimbursement benefits under my insurance policy. I authorize the release of any medical information needed to determine these benefits. This authorization shall remain valid until written notice is given by me revoking said authorization. I understand that I am financially responsible for all charges whether or not they are covered by insurance. A $50.00 cancellation fee will be charged to any and all patients who do not cancel their appointment within 24 hours prior to their scheduled appointments.

        Date of completion*

        PEDIATRIC HEALTH HISTORY FORM
        (Birth – 5 years)
        Kristin Stiles Green, NMD

        MEDICATIONS

        MEDICAL HISTORY

        Has your child had any of the following tests?

        Electroencephalogram

        Psychological evaluation

        Hearing

        Speech/Language

        IMMUNIZATIONS

        FAMILY HISTORY

        PRENATAL HISTORY

        Mother’s health during pregnancy?

        BIRTH HISTORY

        TERM:

        Did your child have any of the following problems shortly after birth?

        Age began:

        SYMPTOMS (mark Y if current, P for past symptoms)

        DIET
        Please describe your child’s typical, daily diet:

        Welcome! We look forward to working with you and your child.

        PEDIATRIC INTAKE FORM
        (6-12 years old)
        Kristin Stiles Green, NMD

        What are your child’s most important health problems?
        List in order of importance, please.

        Previous Illnesses

        Has your child had any of the following tests? When & where?

        Electroencephalogram (EEG)

        Psychological evaluation

        Hearing tests

        Speech/Language tests

        Hospitalizations/ Surgeries/ Injuries

        IMMUNIZATIONS

        Allergies

        Is your child hypersensitive or allergic to?

        Typical Food Intake

        REVIEW OF SYSTEMS FOR YOUR CHILD
        Y = a condition now, P = a condition in the past, N = never had
        MENTAL/ EMOTIONAL

        ENDOCRINE

        SKIN

        HEAD

        EYES

        EARS

        NOSE AND SINUSES

        MOUTH AND THROAT

        RESPIRATORY

        CARDIOVASCULAR

        URINARY

        GASTROINTESTINAL

        MUSCULOSKELETAL

        BLOOD/PERIPHERAL VASCULAR

        Welcome! We look forward to working with you and your child.

        Adult Health History Form
        Kristin Stiles Green, NMD


        SUCCESSFUL HEALTH CARE IS ONLY POSSIBLE WHEN THE PROVIDER HAS A COMPLETE UNDERSTANDING OF THE PERSON PHYSICALLY, MENTALLY AND EMOTIONALLY.
        PLEASE COMPLETE THIS QUESTIONNAIRE AS THOROUGHLY AS POSSIBLE.
        PLEASE, FILL AND MARK ANYTHING YOU DON’T UNDERSTAND WITH A QUESTION MARK.

        Are you hypersensitive or allergic to:

        Current Medications/Supplements/Herbs/Homeopathics:
        Please list ALL vitamins, herbs, supplements AND prescription medications OR over the counter medications you are taking, regularly.
        Please include ingredients, milligram amounts, how often taken, etc.
        For multi-ingredient products, PLEASE BRING IN THE BOTTLES OR CLEAR PHOTOS OF THE FRONT AND BACK LABELS, so I may see the detail.

        CANCER PATIENTS, ONLY

        FOR ALL OTHER CONDITIONS

        SOCIAL HISTORY

        SCREENINGS:

        FAMILY HISTORY

        Please note if any of these disease/problems are/were applicable to your parents, grandparents, uncles, aunts, siblings or children. Please note for whom it was a problem.

        Typical Food Intake – Examples

        EXERCISE

        For the following sections, please use this key:

        Y= a condition you have now   N= a condition you have never had    P= had in the past

        HEAD

        EYES

        EARS

        NOSE AND SINUSES

        MOUTH AND THROAT

        SEASONAL ALLERGIES

        RESPIRATORY

        CARDIOVASCULAR

        BLOOD/PERIPHERAL VASCULAR

        GASTROINTESTINAL

        BONES/BACK/NECK/JOINTS/MUSCLES

        NEUROLOGY

        SKIN

        ENDOCRINE

        IMMUNE

        URINARY/KIDNEY

        MALE REPRODUCTIVE SYSTEM

        FEMALE REPRODUCTIVE SYSTEM

        MENTAL / EMOTIONAL / PSYCHOLOGICAL

        FINANCES

        VIOLENCE

        Welcome!
        We are glad to serve you!

        • Arbitration contract – English 

          PHYSICIAN-PATIENT ARBITRATION AGREEMENT

          Article 1: Agreement to Arbitrate: It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, will be determined by submission to arbitration as provided by California law, and not by a lawsuit or resort to court process except as California law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration.

          Article 2: All Claims Must Be Arbitrated: It is the intention of the parties that this agreement shall cover all claims or controversies whether in tort, contract or otherwise, and shall bind all parties whose claims may arise out of or in any way relate to treatment or services provided or not provided by the below identified physician, medical group or association, their partners, associates, associations, corporations, partnerships, employees, agents, clinics, and/or providers (hereinafter collectively referred to as “Physician”) to a patient, including any spouse or heirs of the patient and any children, whether born or unborn, at the time of the occurrence giving rise to any claim. In the case of any pregnant mother, the term “patient” herein shall mean both the mother and the mother’s expected child or children.
          Filing by Physician of any action in any court by the physician to collect any fee from the patient shall not waive the right to compel arbitration of any malpractice claim. However, following the assertion of any claim against Physician, any fee dispute, whether or not the subject of any existing court action, shall also be resolved by arbitration.

          Article 3: Procedures and Applicable Law: A demand for arbitration must be communicated in writing by U.S. mail, postage prepaid, to all parties, describing the claim against Physician, the amount of damages sought, and the names, addresses and telephone numbers of the patient, and (if applicable) his/her attorney. The parties shall thereafter select a neutral arbitrator who was previously a California superior court judge, to preside over the matter. Both parties shall have the absolute right to arbitrate separately the issues of liability and damages upon written request to the arbitrator. Patient shall pursue his/her claims with reasonable diligence, and the arbitration shall be governed pursuant to Code of Civil Procedure §§ 1280-1295 and the Federal Arbitration Act (9 U.S.C. §§ 1-4). The parties shall bear their own costs, fees and expenses, along with a pro rata share of the neutral arbitrator’s fees and expenses.


          Article 4: Retroactive Effect: The patient intends this agreement to cover all services rendered by Physician not only after the date it is signed (including, but not limited to, emergency treatment), but also before it was signed as well.

          Article 5: Revocation: This agreement may be revoked by written notice delivered to Physician within 30 days of signature and if not revoked will govern all medical services received by the patient.

          Article 6: Severability Provision: In the event any provision(s) of this Agreement is declared void and/or unenforceable, such provision(s) shall be deemed severed therefrom and the remainder of the Agreement enforced in accordance with California law.

          I understand that I have the right to receive a copy of this agreement. By my signature below, I acknowledge that I have received a copy.

          NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HA VE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE I OF THIS CONTRACT.

           

          A signed copy of this document should be given to the patient. The original copy will be archived in the patient’s medical file.



        ACUERDO DE ARBITRAJE MÉDICO-PACIENTE

        Artículo 1: Acuerdo de arbitraje: Se conviene que cualquier disputa relativa a negligencia médica, es decir, a si cualquiera de los servicios médicos
        prestados bajo este contrato fueron innecesarios o no autorizados o llevados a cabo de manera impropia, negligente o incompleta, sea determinada
        por el sometimiento a arbitraje según lo dispuesto por la ley de California, y no por medio de una demanda o el recurso a un procedimiento judicial
        salvo en lo que la ley de California dispone para la revisión judicial de procedimientos arbitrales. Ambas partes, al celebrar este contrato, están
        renunciando a su derecho constitucional a que dicha disputa sea decidida en un tribunal frente a un jurado y, en su lugar, están aceptando el uso
        de arbitraje.

        Artículo 2: Todas las reclamaciones deberán ser sometidas a arbitraje: Es la intención de las partes que este acuerdo cubra todas las
        reclamaciones o controversias contractuales, extracontractuales o de cualquier otro tipo, y vinculará a todas las partes cuyas reclamaciones se
        deriven o se relacionen de cualquier forma con el tratamiento o los servicios prestados o no prestados al paciente
        por el médico, el grupo o asociación médica, sus socios, asociados, asociaciones, corporaciones, entidades sociales, empleados, agentes, clínicas y /o
        proveedores identificado/s más abajo (en adelante, agrupados bajo el nombre de “Médico”), incluido el tratamiento o los servicios prestados o no
        prestados a cualesquiera cónyuges o herederos e hijos del paciente, nacidos o no nacidos, al tiempo de la aparición de los hechos de los que se deriva
        la reclamación. En el caso de una madre embarazada, el término paciente en la presente designará tanto a la madre como al futuro hijo o hijos.
        El inicio por parte de un Médico de una acción ante un tribunal para el cobro de honorarios no significará la renuncia al derecho a exigir el
        sometimiento a arbitraje de cualquier reclamación por negligencia. Sin embargo, tras la interposición de una demanda contra el Médico, cualquier
        disputa por honorarios, esté o no sujeta a un procedimiento judicial, también deberá ser resuelta por arbitraje.

        Artículo 3: Procedimiento y ley aplicable: Las peticiones de arbitraje deberán ser comunicadas por escrito a través del correo postal, con el
        franqueo pagado, a todas las partes, describiendo la reclamación contra el Médico, la indemnización por daños y perjuicios que se pretende, y los
        nombres , direcciones y números de teléfono del paciente y, en su caso, de su abogado. Después de eso, las partes seleccionarán un árbitro de
        equidad que haya sido previamente un juez de un tribunal de instancia superior del estado de California, para entienda en la causa. Ambas partes
        tendrán el derecho de someter separadamente a arbitraje los temas de responsabilidad e indemnización por daños y perjuicios a petición escrita del
        árbitro. El paciente deberá entablar sus reclamaciones con diligencia razonable, y el arbitraje se regirá de acuerdo a los artículos 1280-1295 del
        Código de Procedimiento Civil (Code ofCivil Procedure) y a la Ley Federal de Arbitraje (artículos 1 a 4 del Título 9.0 del Código de los Estados
        Unidos). Las partes deberán pagar sus propios costos, honorarios y gastos, además de costear una parte proporcional de los honorarios y gastos del
        árbitro de equidad.

        Artículo 4: Efecto retroactivo: El paciente tiene el propósito de que este acuerdo cubra todos los servicios prestados por el Médico no sólo después
        de la fecha de su firma (lo cual incluye, entre otros, el tratamiento de emergencia), sino también antes de que fuera firmado.

        Artículo 5: Revocación: Este acuerdo puede ser revocado por notificación escrita entregada al Médico dentro de los 30 días que sig u en a la firma y
        si no es revocado regirá todos los servicios médicos recibidos por el paciente.

        Artículo 6: Disposición de divisibilidad: En caso de que una o varias disposiciones de este acuerdo sea/n declarada/s nula/s y no exigible/s, tal
        disposición o disposiciones deberá/n considerarse nula/s al efecto y el resto del acuerdo será exigible de acuerdo a las normas del estado de
        California.
        Entiendo que tengo derecho a recibir una copia de este acuerdo. Al firmar abajo, reconozco que he recibido una copia.

        ADVERTENCIA: AL FIRMAR ESTE CONTRATO USTED ESTÁ DE ACUERDO CON QUE CUALQUIER PROBLEMA DE NEGLIGENCIA
        MÉDICA SEA DECIDIDO POR ARBITRAJE DE EQUIDAD Y ESTÁ RENUNCIANDO A SU DERECHO A UN JURADO O A UN
        PROCEDIMIENTO JUDICIAL. VEA EL ARTÍCULO 1 DE ESTE CONTRATO.

        Una copia firmada de este documento deberá ser entregada al paciente. El original será archivado en el expediente médico del paciente.


        Other Forms and Documents:

        NEURON MEDICAL CORPORATION

        PHYSICIANS

        Liliana Cohen, M.D.
        Paul Dudley, M.D.
        Kristin Stiles Green, N.M.D 


        227 West Janss Road, #135
         Thousand Oaks, CA 91360
        www.neuronmedical.com
        Phone: 805-373-2890
        Fax: 805-364-5464
        neuronoffice@gmail.com

        SERVICES
        General Neurology
        Botox
        Electromyography
        Electroencephalography
        Naturopathic Medicine

        MEDICAL RECORDS AUTHORIZATION RELEASE


        I herby authorize and request you to release the following medical records:


        (Specify type of medical documents)

        ALL Records:

        H & P:

        Labs:

        MRI & MRA:

        EEG:

        Misc.: