Contact info@NICBWBeverlyhills.comPhone: (310) 299-9799150 N Robertson BlvdBeverly Hills, CA 90211 Name * First Name Last Name Phone (###) ### #### Email * How would you like us to contact you? * Phone Call Email Text Message (SMS) Do you have a preferred callback time * Our supervisors will do their best to return your call during your preferred time. Please understand that they are treating most of the day, but they will make every effort to reach you at your preferred time." Morning Afternoon Evening Who will be the patient? * Yourself Someone Else Did the patient have a stroke or brain injury? * Stroke Brain Injury When was the patient's stroke or brain injury? * MM DD YYYY Did the patient receive any therapy after their stroke or brain injury? * Yes No Is the patient still in therapy? * Yes No Please check the box to confirm you've read the following message. * We are a fee for service clinic. We do not accept any third-party payor or insurance. We do not bill any third-party payor or insurance. We do not fill out any paperwork or forms for any third-party payor or insurance. I read the above statement. Message * Thank you!
