Patients

Work-injury intake.

Name: North County Orthopedic Medical Group
Address: 8929 University Center Ln, Ste 100, San Diego, CA, 92122, US
Telephone: (858) 457-4040
Price range: $$

For California Workers' Comp, Longshore, and federal claims. We'll coordinate with your employer, adjuster, and attorney.

Call (858) 457-4040 All forms

Patient

First name *

Last name *

Date of birth *

Phone *

Email *

Employer & claim

Employer name *

Claim type *

Claim number

Insurance carrier

Adjuster name

Adjuster phone

Adjuster email

Attorney (if any)

Injury

Date of injury *

Body part(s) injured *

How the injury happened *

Has the visit been authorized? *

Do not include sensitive medical information beyond what's asked. For medical emergencies, call 911. No information is stored on your device. Submissions are transmitted securely to our intake system.

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Se habla español · Workers' Comp & Longshore accepted · Most major insurance plans