Patient Forms

New Patients

If you are an existing patient, click here

If you are new to our practice, please fill out the following New Patient Registration Forms for the provider that you will be seeing:

Dr. Fechtel, Dr. Pawar, Dr. Sales, A. McLouth, C. Simons, L. Siniscalchi, S. Hawrylkiw - General NeurologySubmit ElectronicallyDownload/Print
C. O'Neill, Y. Eckrich - NeurobehavioralSubmit ElectronicallyDownload/Print
Dr. Subei - Neuro-Ophthalmology Submit ElectronicallyDownload/Print
Dr. Mahant - Movement DisorderSubmit ElectronicallyDownload/Print
Dr. Bowen, L. Nelson - Headache/MigrainesSubmit ElectronicallyDownload/Print
Dr. Eross, K. Plyer - Headache/MigraineSubmit ElectronicallyDownload/Print
Dr. McCoy - Headache/MigraineSubmit ElectronicallyDownload/Print

What to Bring to An Appointment

  • Patient’s insurance card
  • Physician referral forms, if required by insurance
  • List of prescriptions and/or over-the-counter medications, including dose and frequency
  • Information about the patient’s medical and surgical history
  • Recent x-rays or relevant records

Know Where You Are Going

Foothills Neurology has several offices throughout the Valley. Make sure you are going to the correct office. Below is a list of our 6 locations with the providers available and procedures performed at each office.

Foothills Neurology - Main OfficeFoothills Neurology - Testing CenterFoothills Neurobehavioral Health
4530 E. Muirwood Dr. #111
Phoenix, AZ 85048
4530 E. Muirwood Dr. #114
Phoenix, AZ 85048
15715 S 46th St. #100
Phoenix, AZ 85048
General Neurology New Patients, Follow Ups, Consults, Physical Therapy, Ophthalmology, Optical ExaminationsEEG, EMG, NCS, VEP, Infusions, Headache/Migraine PatientsPsychiatry Patients, TMS, Neurocognitive Testing
Dr. Fechtel, Dr. Mahant, Dr. Pawar, Dr. Sales, Dr. Subei, A. McLouth, C. Simons, L. Siniscalchi, M. Diedrich, S. HawrylkiwDr. Bowen, Dr. Visser, L. NelsonC. O'Neill, J. Richi, M. Preston, R. Ibarra, Y. Eckrich

Phoenix Headache Insitute - PHIIntegrative Headache CareFoothills Neuro-Ophthalmology
7054 E. Cochise Rd. #B230
Scottsdale, AZ 85253
15169 N Scottsdale Rd #350
Scottsdale, AZ 85254
4001 N. 3rd St. #290
Phoenix, AZ 85012
Headache/Migraine Patients, InfusionsHeadache/Migraine Patients, InfusionsOphthalmology, Eye Examinations, VEP, OCT, Fundus, EEG
Dr. Eross, K. PlyerH. McCoyDr. Subei

Existing Patients

If you are a new patient, click here

Symptoms / Conditions Downloads

General Neurology - New ProblemDownload/Print
Dr. Bowen New ProblemDownload/Print
Headache DiaryDownload/Print
Balancing Body Chemistry Health AssessmentDownload/Print

Privacy and Release Downloads

Medical Records RequestSubmit ElectronicallyDownload/Print
Medical Records FeeDownload/Print
HIPPA Privacy NoticeDownload/Print

Headache Forms Downloads

Blank Trigger Tracker-PHIDownload/Print
Trigger Tracker-PHIDownload/Print
Headache Tracker-PHIDownload/Print
Headache Impairment Questionaire-PHIDownload/Print
Headache Impairment Tracker-PHIDownload/Print

Diagnostic Exam Preperations

Routine EEG InstructionsDownload/Print
Ambulatory EEG InstructionsDownload/Print
Foothills Neurology