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Tel: (818) 239-9293
Fax: (818) 239-4525
info@cordialhp.com
600 N. Brand Blvd., Suite 612 Glendale, CA 91203
Intake Form
Complete the form below to submit a new patient referral so we can schedule a visit as soon as possible.
Make sure to double check your data before submitting.
Patient Information
--- Choose Gender ---
Male
Female
--- Residence Type ---
Home
Facility
--- Needs Interpreter? ---
Yes
No
Insurance Information
Preferred Supervising MD
DR. FIDEL M LARA JR., MD
DR. DARRIN LUU, MD
DR. PAULA BAILEY-WALTON, MD
DR. DANIEL LINARES, MD (Only for follow-up/existing patients)
Reason for Visit
--- Type of Assessment ---
Start of Care
Recertification
Resumption of Care
--- Reason for Visit ---
Referral to Home Health
Discharged from Hospital
Other Reason
--- Type of Visit ---
Home Visit
Telehealth
Either
Thank you for choosing us. You should receive a confirmation email. If you don’t receive a confirmation email, please call us at (818) 239-9293.
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