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Page 1: Thomas W. LaGrelius, M.D., F.A.A.F.P. Diplomate American

EMAIL: [email protected]

Thomas W. LaGrelius, M.D., F.A.A.F.P. Diplomate American Board of Family Practice and Geriatric Medicine

Nicole Z. Lawrence, M.D. Board Certified in Internal Medicine and Geriatric Medicine

Jeffrey M. Karns, M.D. M.D. Board Certified in Family Practice

Tel: (310) 378-6208 Fax (310) 378-2564 WEBSITE: www.skyparkpfc.com

SKYPARK PREFERRED FAMILY CARE 23451 Madison St., Suite 140, Torrance, CA 90505

Name & Phone Number of Emergency Contact not living with you: Name _________________________________________ Phone _________________

Okay to use: Yes No

Page 2: Thomas W. LaGrelius, M.D., F.A.A.F.P. Diplomate American

Shingles Vaccine Mo. ____ Yr. _____

Prevnar Vaccine Mo. Yr.

Page 3: Thomas W. LaGrelius, M.D., F.A.A.F.P. Diplomate American

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