Home » Evaluation Form
If you would like to download a PDF version of the evaluation form to print out and bring in at the time of your first appointment INSTEAD of filling it out online, please click HERE.
2730 Wilshire Boulevard, Suite 325, Santa Monica, California 90403
Telephone: (310) 828-5015
Fax: (310) 829-3877
Welcome to our office!
Thank you for making an appointment with Dr. Fogelson. Thank you for taking the time to complete this important questionnaire and forwarding it to us prior to your appointment. Please be sure to fill out all pages. Directions and a map indicating the location of the office may be found on this website.
We want you to understand our medical specialty and to feel comfortable in our office. The pamphlets on the National Institute of Mental Health's website may answer some questions for you. Other areas of this website explain office procedures. Please feel free to ask Dr. Fogelson or myself any questions that may remain unanswered.
Dr. Fogelson received his medical degree from Harvard Medical School and his graduate training in Psychiatry from UCLA. He is a Clinical Professor in the UCLA Department of Psychiatry and Biobehavioral Sciences. Dr. Fogelson is a general psychiatrist for adults. He specializes in medication treatments and psychotherapy.
Dr. Fogelson and I look forward to meeting you.
P.S. If the doors to the building are locked, please use the breezeway entrance along the side of the building. You can let yourself into the building by entering the code 7353.
David L. Fogelson, M.D., Inc.
Consent for Evaluation or Treatment
Please take a moment to review some information to which you are entitled before receiving psychiatric services.
Any information you disclose will be maintained in the strictest confidence, unless you specifically authorize its release, or unless its release is required by law or professional standards of practice. In particular, your right to confidentiality may not be maintained if you are an immediate danger to yourself or to someone else, and steps must be taken to assure your own or another’s safety. Also, any clinician hearing about domestic violence from a patient or that a child or elder is being or has been physically or psychologically abused is required by law to report this information to a designated agency. If it is necessary to disclose some information you have provided, to anyone else, this will be discussed with you.
All outpatient visits must be paid for at the time of the visit. Dr. Fogelson is not a provider for any of the insurance networks. At the time of your outpatient visit, you will be provided with an insurance statement to submit to your insurance company. We cannot accept responsibility for negotiating claims with insurance companies or other persons. You are responsible for payment of your medical care regardless of the status of your claim. Any other financial arrangement must be made with us prior to service.
It is important for your continued medical care that you have routine follow up appointments so that the doctor can monitor your care. Therefore, if you have not returned to see the doctor by three months after the date of recommended return to the office, we will consider the doctor patient relationship terminated and no prescription refills will be granted after this period.
Any outstanding bills will be rebilled monthly. If payment is not received after two successive billings, your account may be sent to a collection service. Should you need to cancel a session, please do so at least 48 business hours in advance. Otherwise you will be charged at your regular rate for the cancelled session. Under circumstances where a party other than the patient is responsible for payment, that party must sign a separate agreement guaranteeing payment of the bill.
There is a returned check charge of $20.00.
I agree in the event of non-payment to bear the cost of collection and/or court costs and legal fees should this be required.
I have read and understood the foregoing, and I consent to this evaluation or treatment.
Copyright 2014 Dr. David Fogelson