Access Medical Labs - Traumatic Brain Injury Form

Mark L. Gordon, M.D.

I agree

to using TeleHealth.

I am

a Veteran.

I am

presently on Active Duty.

I am

receiving Medi-Care benefits.

My case

is URGENT. Please start my program Now.

LAST Name:

FIRST Name:

Date of Birth:

Email:

Skype Name:

Telephone:

Street:

City:

State & ZIP:

Country:

Refer me if available:

Symptoms:

Number of TBI:

Condition:

Date of TBI(s):

Type of Injury:
(Multiple selections allowed) Use SHIFT+Lt Click:

Describe TBI:

Glasgow Score:

Status:

Initial Care:

Subsequent Care:

Hospitalized:

Medication:

List Medication:

My Physician is:

MD Phone#

MD address :

MD City-State-Zip:

Referred by:

Name:

Legal Status:

If Active Litigation:

Lawyers #: