Self-Referral Screening

Please make sure to read, print, fill out and submit to Dr. Etebar’s office, by mail or in person.
Read instructions and click icon below to download this PDF file

What is Self-Referral Screening?

New patient appointments are scheduled by referral from a physician to Dr. Shahin Etebar. Otherwise, patients who wish to refer themselves are required to undergo a Self-Referral Screening to determine if they will receive an appointment with Dr. Etebar,
which is free of charge.

How does the screening process work?

In order to be screened, you must have had an MRI or CT myelogram or CT scan of the symptomatic region of your spine (or brain) within the past 12 months. You must submit the required material (see the checklist below) to Dr. Etebar’s office by mail or in person. Dr. Etebar will personally review the material you have submitted, for no charge. He will use the available information to determine if he can be effective in further evaluation and treatment. Within a few days, you will be notified by phone about whether you have been accepted for an appointment. If you have not heard from his office within one week, you may call us to check on the status of your screening.

Self-Referral Screening Checklist

The following material should be submitted to Dr. Etebar’s office, by mail or in person:

• MRI or CT images: These can be submitted on a CD (preferable) or on printed film. These will not be mailed back to you. If you are not accepted for an appointment, you will be given one month to pick up the films in person.
• Written radiologist report of the studies you bring.
• Completed Self-Referral Questionnaire (download above)
• Signed acknowledgement of the Terms and Conditions of Self-Referral Screening (download above)