DROHMYBACK.COM - Contact

PEACE OF MIND, BALANCED BODY ™

*MAKE AN APPOINTMENT TODAY*

CONTACT

BRUMFIELD SPORTS AND FAMILY WELLNESS CENTER
8727 La Tijera Blvd., Suite B
Los Angeles, CA 90045
(VIEW OUR OFFICE)

e-mail address: drbrumfield@drohmyback.com
tel: 310.348.0592
toll free: 866.DR.O.MYBK
fax: 310.348.0067

Hours of Operation:
Monday & Tuesday 2:00pm to 7:00pm
Thursday & Friday 2:00pm to 7:00pm

Map:
- Click on the map to Enlarge -

Making An Appointment? (CLICK HERE)
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Purchase discounted items below.
New Patient Coupon/Gift Certificate Please print out the New Patient Coupon/Gift Certificate by clicking the link above. Bring it, and copy of your PayPal receipt, to your appointment.
Jump Start to Wellness Coupon Please print out the Jump Start to Wellness Coupon by clicking the link above. Bring it, and copy of your PayPal receipt, to your appointment.

1. Patient Information:

*required

*Full Name:

*Contact Number:

i.e. 555-555-5555

*E-Mail Address:

i.e. you@yahoo.com

Age:

*Date of Birth:

i.e. MM/DD/YYYY

*Social Security #:

i.e. 555-55-5555

*Sex:

Are you here because you were involved in a vehicle collision?

Are you here because you were injured at your place of employment?

Are you here because you were involved in another type of accident?

*Who is responsible for this account?

If "other," please provide Full Name:

**Will you be using health insurance to supplement payment to our office?

**If YES, please complete the INSURANCE COVERAGE and INSURED INFORMATION sections of this form.

2. Insurance Coverage:

Type of Insurance:

Primary Insurance Company:

Primary Insurance Contact Number:

i.e. 555-555-5555

Primary Insurance ID#:

Primary Insurance Group#:

Secondary Insurance Company:

Secondary Insurance Contact Number:

i.e. 555-555-5555

Secondary Insurance ID#:

Secondary Insurance Group#:

3. Insured Information:

Are the insured and patient the same person? If YES, do not complete SECTION 3.

Full Name:

Street Address #1:

Street Address #2:

City:

State:

Zip Code:

Age:

Date of Birth:

i.e. MM/DD/YYYY

Social Security #:

i.e. 555-55-5555

Sex:

Relationship to Insured:

If "other," please reply:

Questions/Comments: