LG - THE CHILD NEUROLOGY EXPERT

Name of Parent or Legal Guardian *

First

Last

Child's Gender and Age *

Mailing Address *

Line 1

Line 2

City

State

Zip Code

Country

How did you hear about Child Neurology Consulting? *

Email address *

Phone Number #1 *

Phone Number #2 *

Have you spoken to or retained an attorney? *

Spoken, have not retained one yet Retained Neither N/A

What would you like to discuss with Dr. Nelson (please be specific): *

Preferred time of conference call: *

Morning Afternoon Evening Doesn't matter; prefer soonest available

Please carefully review Dr. Nelson's fee schedule attached before submitting this form.
You do not need to mail us a signed copy if you're providing your electronic signature below.

I have reviewed Dr. Nelson's fee schedule and confirm my agreement by entering my full name below: *

Electronically signed by me on (enter today's date): *

PARENT CONFERENCE FORM