Practitioner Consultations

At the request of licensed physicians or nurse practitioners, Dr. Mozayeni and his team will consult on the care of individual patients. We also provide education and training periodically based on demand.

Please complete the short form below to request a consultation and/or to sign up for educational program announcements.

For consultations, there will be a consultation fee, to be paid in advance. Practitioners requesting a consultation will be charged directly because we would be consulting to the practitioner on behalf of the patient and not directly to the patient. The practitioner would then charge their patient for our consultation plus their professional fee. Under this arrangement, the doctor-patient relationship remains entirely between the practitioner requesting the consultation and their patient and we would not have any direct communication or relationship with the patient.

    Name of Practitioner (required)

    Your Email (required)

    Phone Number

    Phone Number Other

    Address

    State of Licensure

    Type of License MDNurse Practitioner

    License Number

    License Expiration

    Type of Practice and Specialization

    Description of Case
    (** For patient privacy, do not include patient name or other identifier in this message **)

    Purpose and Objectives of Consultation

    Urgent
    yesno

    Would you be interested in receiving announcements regarding educational programs and seminars?
    yesno

    What topics would be of interest to you?

     

     

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