LOD Readiness Checklist

1

Please type your NAME.* This field is required.

First Name

Last Name

2

Please type your Email* This field is required.

example@example.com

3

Phone Number* This field is required.

Please enter a valid phone number.

4

Have you received your APPOINTMENT date?

YESNO

5

Do you need to arrange TRAVEL to your appointment?* This field is required.In the event Legacy has spoken to you about specific travel, please select "NO". Please be advised, you must travel from the city listed on your application. FOR HOTEL stays please note, you will need a card with $100 for incidentals upon check in at the hotel.

YESNO

6

Do you need to arrange TRAVEL to your appointment?* This field is required.Please be advised, you must travel from the city listed on your application. FOR HOTEL stays please note, you will need a card with $100 for incidentals upon check in at the hotel.

YES

NO

Spoke with Legacy about Alternate Travel

7

To Arrange Travel, you will call ART SOLIS at 310-752-9157(COPY for now), please call after this form is complete. Completion of this form allows you to set your prep appointment.

Please save this number for AfterHours (after 5p pst) and Weekend assitance (877) 894-9111.

Please tell them you are with Legacy so that they forward your itinerary to us!

8

Have you received your PACKET to print?

YESNO

9

Did you have MRIs done?If yes, please take your disc with you to the appointment.

YESNO

10

Have you set your LOD PREP appointment (This is NOT your appointment date)?

YESNO

11

LOD Prep* This field is required. This should be scheduled before your appointment date. Please do NOT schedule this prep on the day of your appointment.