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?
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What topics would be of interest to you?

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