OFFICE LOCATION
11190 Warner Avenue
Suite 310
Fountain Valley, CA 92708
Phone (714) 979-2401
Fax (714) 966-0837

APPOINTMENTS AND WAITING TIME

Please call the office to make an appointment in advance. We will do our best to accommodate you in a timely manner. True emergencies are always given priority. New patient appointments typically last at least 45 minutes, please bring a book or other work to do to help pass the time. We make every attempt to adhere to our appointment schedule while trying to accommodate our established patients as well as our new patients. If you are unable to keep your appointment, please call us as soon as possible so that we may reschedule your appointment. Below is our weekly schedule:

   
Monday
Tuesday
Wednesday
Thursday
Friday
8:30am - 12pm
SURGERY
Office hours in
Fountain Valley
SURGERY
SURGERY
SURGERY
2 pm – 5 pm
SURGERY
Office hours in
Fountain Valley
Office hours in
Fountain Valley
SURGERY
Office hours in Fountain Valley
*There are times when Dr. Mudiyam must perform emergency surgeries or attend to urgent hospital matters on patient days and we appreciate your understanding if we run late.

If you cannot access the forms you can click on the icon to download the software.

NEW PATIENT PAPERWORK
As directed by our office please download the forms and bring them completed to your scheduled office visit. This will help expedite the registration process. Thank you.

PATIENT INFORMATION SHEET

PATIENT MEDICAL HISTORY FORM

PATIENT PAIN DRAWING


PATIENT CONSENT FORM

NOTICE OF PRIVACY PRACTICES

FINANCIAL POLICY

If you have neck pain please fill out the following questionnaire:

NECK DISABILITY QUESTIONNAIRE

If you have low back pain or leg pain please fill out the following questionnaire:

OSWESTRY DISABILITY QUESTIONNAIRE

PAYMENTS AND INSURANCE PLANS

We request payment arrangements for all office services at the time they are rendered unless prior arrangements have been made. We accept Medicare and most PPO plans. We are not a part of any HMO plans and do not accept third party insurance. If we are a participating provider of your insurance company, we will bill them. However, payment is the patient’s responsibility. We will help in any way we can to assist you in handling claims. We accept cash, checks, debit cards and major credit cards.

PRESCRIPTIONS AND REFILLS

Please request all prescriptions and refills through your pharmacy between 8am-4pm Monday through Friday. We do NOT refill prescriptions on weekends. After you contact your local pharmacy with your request, they will call us with the correct medication name and dosage to ensure your prescription is accurate. We recommend you request your refills at least one day before you run out of medication so that you will never be without them.

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